Columbia  (intt)em'tp 

CoUegc  of  ^Ijpgiciansj  anb  ^urgconjs 
l.iftrarp 


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A  MANUAL 

of 

GYNECOLOGY 


BY 

JOHN  COOKE  HIRST,  M.  D. 

Associate  in  Obstetrics,  University  of  Pennsylvania;  Obstetrician 
and  Gynecologist  to  the  Philadelphia  General  Hospital;  Obstet- 
rician to  St.  Agnes  Hospital;  Gynecologist  to  Mt.  Sinai  Hospital; 
Gynecologist  to  the  American  Hospital  for  Diseases  of  the 
Stomach;    Fellow  of    the    College    of    Physicians,    Philadelphia 


WITH  176  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1918 


Copyright,  1918,  by  W.  B.  Saunders  Company 


PRINTED     IN    AMERICA 

PRESS    OF 

W.    B.    SAUNDERS    COMPANY 

PHILADELPHIA 


TO   THE   CLASSES  OF  THE   MEDICAL   SCHOOL  OF 

THE   UNIVERSITY  OF  PENNSYLVANIA,  PAST 

PRESENT  AND  FUTURE,  THIS  BOOK 

IS    DEDICATED    BY    THEIR 

FELLOW-STUDENT, 

The  Author. 


PREFACE 


The  author  has  attempted  in  this  volume,  so  far  as  it  is 
possible  to  do  so  on  the  printed  page,  to  present  the  arrange- 
ment of  the  subject  he  has  used  in  teaching  during  the  last 
twenty  years.  His  ainj  has  been  to  present  the  subject 
concisely,  accurately  and  without  unnecessary  waste  of  space. 

In  several  sections,  notably  those  on  the  injuries  of  child- 
birth, their  consequences,  diseases  of  the  breasts  and  hemor- 
rhage, he  has  thought  it  best  to  consider  the  subject  from  the 
point  of  view  of  both  the  obstetrician  and  the  gynecologist, 
as  the  two  are  so  intimately  connected  that  to  present  it  in 
any  other  way  would  be  at  the  expense  of  thoroughness  and 
clarity. 

Throughout  the  book,  an  effort  has  been  made  to  omit 
unprofitable  discussion,  and  to  give  to  the  student,  be  he 
graduate  or  undergraduate,  at  least  one  method  of  treatment 
which  has  proven  its  value,  as  a  basis  on  which  to  build  as 
suggested  by  the  individual's  own  experience. 

A  special  chapter  deals  witli  leukorrhea  alone,  one  of  the 
commonest  disorders  for  which  a  patient  consults  her  physician, 
and  yet  one  which,  because  it  is  a  symptom  and  not  usually 
a  primary  condition,  is  too  frequently  passed  over  in  the 
discussion  of  its  primary  cause. 

The  operation  of  dilatation  and  curettage  of  the  uterus — 
in  the  author's  opinion  is  one  of  the  most  important,  because 
of  its  supposed  minor  character — has  been  given  somewhat 
extended  space,  being  described  three  times,  as  its  technic 
varies  slightly  for  different  indications. 

11 


12  PREFACE 

Illustrations  have  been  placed  to  make  more  clear  the  points 
about  which  students  have  most  often  questioned  the  author, 
and  where  he  believes  their  presence  is  an  addition  to  the 
explanations  in  the  text.  No  attempt  at  lavish  illustration 
has  been  made. 

The  book  is  presented  with  the  sincere  hope  that  it  may 
achieve  the  purpose  for  which  it  was  written:  to  give  to  the 
medical  student  a  reasonably  concise  and  accurate  outline 
of  the  subject,  and  to  the  busy  practitioner  the  information 
he  may  seek,  without  the  need  of  voluminous  reading. 

•  J.  C.  Hirst. 

1823  Pine  Street, 
Philadelphia,  Pa., 
November,  tqi8. 


CONTENTS 


CHAPTER  I 

Page 

Normal  Pelvic  Anatomy 17 

The  External  Generative  Organs 17 

The  Internal  Generative  Organs 20 

CHAPTER  II 

Methods  of  Examination.     Office  Treatment 25 

Examination  of  Patient 26 

Methods  of  Local  Treatment 41 

CHAPTER  III 

Anomalies  of  Development.     Hermaphroditism.     Sterility    .    .     48 

CHAPTER  IV 

Diseases  of  the  Vulva 57 

CHAPTER  V 

Diseases   of   the   Vagina,  Excluding  Lacerations  and  Their 
Consequences    69 

CHAPTER  VI 

Abnormalities  of  the  Cervix  Excluding  Tears 78 

Abnormalities  of  the  Cervix 79 

CHAPTER  VII 

The  Uterus — Its  Normal  Position  and  Relations,  Its  Abnor- 
malities OF  Position  and  Diseases 100 

Abnormalities  and  Diseases  of  Uterus 103 

13 


14  CONTENTS 

CHAPTER  VIII 

Page 

Diseases  of  Fallopeajn"  Tubes 153 

I.  Normal  Anatomy  and  Relations  of  Fallopian  Tubes     ....  15.3 

II.  Congestion  of  Fallopian  Tubes 155 

III.  Extra-Uterine  Pregnancy(Ectopic  Gestation;  Tubal  Gestation)  156 

IV.  Hematosalpinx 162 

V.  Hydrosalpinx  (Hydrops  Tubae;  Sacrosalpinx  Serosa)     .    .    .    .163 

VI.  Salpingitis 164 

VII.  Tuberculosis  of  Fallopian  Tubes 179 

VIII.  Tumors  of  Fallopian  Tufces 180 

IX.  Varicocele  of  Pampiniform  Plexus 181 

CHAPTER  IX 

Diseases  of  Ovary 182 

Abnormalities  and  Diseases 185 

CHAPTER  X 

Diseases  of  the  Peritoxeum  and  Pelvic  Coxxectr^e  Tissue   .    .  207 

I.  Pelvic  Cellulitis  (Parametritis) 208 

II.  Pelvic  Hematocele  (Parametrial  Hematoma; 213 

III.  Peritonitis 214 

IV.  Drainage  of  the  Abdomen,  after  Operation  for  Pelvic  Infection  216 
V.  Phleboliths 219 

CHAPTER  XI 

.Abxorilalities  of  Abdominal  Wall 220 

I.  Diastasis  of  the  Recti  T;\ath  General  Visceroptosis 220 

II.  Exstrophy  of  the  Bladder 221 

III.  Hernia 221 

IV.  Obesity ■ 225 

V.  Patent  Urachus 226 

CHAPTER  XII 

Injuries  of  Birth  Canal  and  Their  Repair 228 

Classification  of  Injuries _ 228 

Injuries  to  the  Pelvis 229 

Rupture  of  the  Uterus 229 

Lacerations  of  the  Cervix 229 

Lacerations  of  the  Anterior  Vaginal  Wall 235 

Vesicovaginal  Fistula 237 

Tears  of  the  Posterior  Vaginal  Wall  and  Perineum 237 


CONTENTS  15 

CHAPTER  XIII 

Page 

Pathological  Sequels  of  Childbirth 256 

VI.  Floating  Kidney 256 

VII.  Fracture  of  Coccyx 260 

VIII.  Relaxation  of  the  Sacro-Iliac  Joints .  262 

IX.  Rectocele 262 

X.  Cystocele 263 

XI.  Prolapse  of  Uterus 271 

XII.  Incontinence  of  Urine 277 

XIII.  Genital  Fistulae 278 

CHAPTER  XIV 

Diseases  of  the  Urinary  Tract  Including  Cystoscopy     .    .    .  283 

Cystoscopy 285 

Uses  of  Ureteral  Catheter 288 

Segregation  of  Urine ■   .    .    .  288 

Pyelography 288 

Diseases  of  the  Urinary  Tract 289 

CHAPTER  XV 

Gonorrhea .' 305 

CHAPTER  XVI 

Normal  Menstruation  and  Its  Abnormalities 317 

Abnormalities  of  Menstruation 322 

CHAPTER  XVII 

Leukorrhea  (The  Whites) 336 

CHAPTER  XVIII 

Diseases  of  Breast. 343 

I.  Anomalies  of  Development 343 

II.  Abnormalities  of  the  Nipple 343 

III.  Non-Inflammatory  Diseases  of  Breast 347 

IV.  Inflammatory  Diseases  of  the  Breast 348 

V.  Tumors  of  the  Breast 354 


■'■"  CONTENTS 

CHAPTER  XIX 
Diseases  of  the  Rectum  ^^^^ 

I.  Congenital  Malformations ^^^ 

II.  Fissures  of  the  Anus  ^^° 

III.  Fistula  in  Ano .'.'.'.'.' ^^' 

IV.  Foreign  Bodies  in  the  Rectum ^^^ 

V.  Hemorrhoids  (Piles) •    •    • 363 

VI.  Proctitis  (Inflammation  of  the  Rectum) ^^o 

VII.  Injuries  of  the  Rectum    ...  ^yi 

VIII.  Ischiorectal  Abscess     ....       ' ^ 

IX.  Prolapse  of  Rectum.    .  ^ 

X.  Pruritus  Ani '    '    ' ^^^ 

XI.  Stricture  of  the  Rectum ^^° 

XII.  Ulcers  of  the  Rectum  ^^^ 

373 

CHAPTER  XX 

Electkicity,  x-ray,  Radium,  Mesothorium  and  Finsen  Light      ,74 

Radium. ^^^ 

Mesothorium •^''^ 

Finsen  Light.  ^  ■^ 

383 

CHAPTER  XXI 

Endocrin  Glands  AND  Their  Extracts  m  Gynecology 384 

CHAPTER  XXII 
General  Technic  of  Gynecologic  Surgery 

Treatment  of  Complications  after  Operation  .....[    [    '  419 

Index      

441 


A  MANUAL  OF  GYNECOLOGY 


CHAPTER  I 

NORMAL  PELVIC  ANATOMY 

The  female  genitalia  are  divided  into  (i)  external  and  (2) 
internal  organs.  The  external  organs  are  (i)  Mons  Veneris; 
(2)  Labia  majora;  (3)  Labia  minora;  (4)  CHtoris;  (5)  Hymen; 
(6)  Vagina,  which  may  properly  be  included  under  this  head. 
The  internal  organs  are:  (i)  The  Uterus;  (2)  The  Fallopian 
tubes  and  (3)  The  Ovaries.  The  following  is  a  brief  descrip- 
tion of  these  organs. 

THE  EXTERNAL  GENERATIVE  ORGANS 

The  mons  veneris  is  the  name  given  to  the  fatty  cushion 
resting  upon  the  anterior  surface  of  the  symphysis;  covered, 
in  the  adult,  with  a  more  or  less  profuse  growth  of  hair.  In 
the  female  the  area  covered  by  the  hair  is  triangular,  its 
base    corresponding,  to    the    upper    edge   of    the    symphysis. 

The  vulva  is  the  name  given  to  the  structures  lying  beneath 
the  mons  veneris.  Its  direction  is  horizontal,  when  the 
woman  is  erect.  It  varies  greatly  in  appearance,  depending 
particularly  upon  whether  or  not  the  woman  has  borne 
children. 

The  labia  majora  are  two  elongated,  rounded  masses  of 
fatty  tissue  covered  by  skin  extending  down  on  either  side  of 
the  vulva.  They  are  usually  7  to  8  cm.  in  length,  2  to  3  cm. 
wide  and  i  to  1.5  cm.  thick,  becoming  narrower  and  thinner  at 
their  lower  extremities.  They  vary  in  appearance,  depending 
upon  the  amount  of  subcutaneous  fat.  In  virgins  and  nullip- 
2  17 


1 8  NORMAL  pel\t:c  anatoaiy 

arous  women  they  are  in  close  approximation,  while  in  women 
who  have  borne  children,  they  frequently  gape  widely.  They 
are  analogous  to  the  scrotum  in  the  male. 

The  labia  minora  are  two  narrow,  triangular  folds  of  tissue, 
seen  between  the  upper  part  of  the  labia  majora,  when  these 
are  separated.  They  converge  anteriorly,  surrounding  the 
clitoris,  while  posteriorly  they  merge  gradually  into  the 
labia  majora. 


Prepuce 
Labium  maius 

-Labium  millu5 


■AntenorVciqmal 
Wall 


Pig.   I. — Diagram  df  the  external  genitalia. 


The  clitoris  is  analogous  to  the  penis  in  the  male,  but  differs 
in  having  no  corpus  spongiosum  and  no  urethra.  It  consists 
of  a  glans,  a  corpus  and  two  crura,  and  is  rarely  more  than 
2  cm.  long.  Its  glans  is  enclosed  by  the  upper  portion  of 
the  two  labia  minora. 

The  vestibule  is  the  almond-shaped  area  extending  from  the 
clitoris  to  the  fourchet,  bounded  laterally  by  the  labia  minora. 
The  portion  between  the  fourchet  and  the  vaginal  opening  is 


THE  EXTERNAL  GENERATIVE  ORGANS 


19 


called   the  fossa  navicularis,  and  is  usually  obliterated   by 
childbirth. 

The  vulvovaginal  glands,  or  Bartholin's  glands  are  two 
compound  racemose  glands,  about  the  size  of  a  small  bean. 
They  are  situated  under  the  constrictor  vaginae,  behind  the 
lower  portion  of  the  labia  majora.  Their  ducts,  2  cm.  long, 
open  on  the  sides  of  the  vestibule, 
just  outside  of  the  vaginal  opening. 
They  are  a  frequent  lurking  place 
of  gonorrhea.  They  are  sometimes 
called  the  glands  of  Duverney,  who 
first  described  them  in  the  cow. 

Skene's  glands  are  situated  in  the 
floor  of  the  urethra,  to  either  side 
of  the  middle  line.  They  are  small 
secretory  canals,  about  half  an  inch  ^' 
long,  whose  function  is  probably  that 
of  lubrication.  A  third,  smaller 
gland  is  situated  in  the  roof  of  the 
urethra.  Ordinarily  the  ducts  open 
through  minute  orifices  inside  the 
meatus,  but  when  inflamed  are  visible 
at  the  meatus.  Gonorrhea  is  prac- 
tically the  only  cause  of  their  in- 
flammation. 

The  hymen  is  the  membranous 
structure  which  more  or  less  completely  occludes  the  vaginal 
opening.  It  presents  marked  differences  of  shape  and  thick- 
ness. The  most  common  shape  of  the  hymenal  opening  is 
crescentic  or  circular.  The  most  important  of  the  other  forms 
are  the  septate,  the  cribriform  and  the  fimbriated  hymen.  It 
is  usually  ruptured  at  the  first  coitus,  the  ruptures  being  mul- 
tiple and  most  often  in  the  posterior  portion.  It  is  usually 
destroyed  by  childbirth,  the  atrophied  remains  being  known 
as  myrtiform  caruncles.  Very  rarely  it  is  imperforate.  It 
may  also  persist  unruptured  after  coitus  or  even  childbirth. 


Pig.  2. — Section  illustrat- • 
ing  the  characteristic  form 
of  the  vaginal  cleft:  Ua, 
Urethra;  Va,  vagina;  L, 
levator  ani;  R,  rectum. 
{Henle.) 


20  NORMAL   PELVIC    ANATOMY 

The  vagina  is  a  musculomembranous  canal  extending  from 
the  vulva  to  the  uterus.  It  runs  through  the  pelvic  floor,  and 
its  walls  are  normally  in  close  apposition.  A  cross-section 
of  the  vagina  resembles  the  letter  H.  The  vagina  is  about 
8  cm.  long  anteriorly  and  lo  cm.  long  posteriorly.  The 
shape  of  the  anterior  and  posterior  walls  is  triangular,  the 
canal  being  broadest  near  the  cervix.  A  prominent  longitu- 
dinal ridge  projects  from  both  the  anterior  and  posterior  walls, 
known  as  the  anterior  and  posterior  vaginal  columns.  From 
this  ridge,  in  women  who  have  not  borne  children,  extend 
numerous  transverse  folds,  known  as  rugae.  These  disappear 
after  repeated  childbirth,  and  the  vaginal  walls  are  then 
frequently  smooth.  The  vagina  is  lined  by  a  mucosa  composed 
of  numerous  layers  of  stratified  squamous  epithelium.  The 
vaginal  mucosa  contains  no  glands.  In  embryos  the  vagina  is 
composed  of  a  solid  mass  of  polygonal  cells.  The  vaginal 
lumen  is  formed  about  the  third  month  of  fetal  life,  by  the 
degeneration  of  these  cells. 

THE  INTERNAL  GENERATIVE  ORGANS 

The  uterus  is  a  hollow  muscular  organ,  partially  covered 
with  peritoneum.  It  lies  in  the  pelvis,  between  the  bladder 
and  the  rectum.  Its  axis  is  approximately  at  right  angles 
to  the  vagina.  It  is  pear-shaped,  slightly  flattened  antero- 
posteriorly,  and  consists  of  a  body  and  a  neck  or  cervix. 
The  uterus,  in  the  adult  female  is  about  two  and  one-half 
inches  long  and  weighs  about  two  ounces.  The  uterus  is 
composed  of  an  inner  epithelial  layer,  a  middle  muscular 
layer  and,  in  its  upper  two-thirds,  an  outer  or  peritoneal  layer. 
The  inner  layer,  which  lines  the  cavity,  is  called  the  endo- 
metrium. It  is  a  thin  velvety  membrane,  about  one  or  two 
millimeters  in  thickness,  composed  of  a  surface  epithelium, 
a  stroma  of  short  spindle  cells,  and  small  tubular  glands, 
lined  by  columnar  epithelium.  The  surface  epithelium  is  a 
single  layer  of  ciliated  columnar  epithelial  cells.     The  stroma 


THE     INTERNAL     GENERATIVE     ORGANS  21 

contains  numerous  blood  and  lymph  channels.  In  the  cervix 
are  seen  numerous  ridges  of  mucous  membrane,  radiating 
from  a  central  ridge,  the  figure  being  known  as  the  arhor 
vitcB  or  plica  palmatcs. 

The  uterine  muscle,  or  the  myometrium,  is  composed  of 
bundles  of  non-striated  muscle  fibers,  united  by  connective 
tissue  containing  many  elastic  fibers.  The  arrangement  of 
these  bundles  is  still  a  matter  of  dispute.  The  uterine  blood- 
vessels are  very  numerous,  and  pierce  the  uterine  wall  in  all 
directions. 

The  ligaments  of  the  uterus  are  ten  in  number,  viz.:  Two 
broad,  two  round,  two  uterosacral,  two  uterovesical  and  two 
cardinal.  In  the  bases  of  the  broad  figments  are  two 
bands  of  dense  connective  tissue  which  are  often  regarded  as 
ligaments  of  the  uterus — the  cardinal,  ligaments.  They  are 
attached  to  the  supravaginal  portion  of  the  cervix.  The 
uterine  ligaments  are  partly  suspensory  and  partly  act  as 
guy  ropes. 

The  blood-vessels  of  the  uterus  are  the  uterine  and  ovarian 
arteries,  which  anastomose  and  send  numerous  branches  to  the 
uterus.  There  is  quite  free  communication  between  the  vessels 
on  the  two  sides  of  the  uterus.  The  veins  form  a  large 
plexus  around  each  uterine  artery,  form  the  uterine  veins 
and  empty  into  the  hypogastric  vein.  The  return  blood  from 
the  ovary  and  upper  part  of  the  broad  ligament  is  collected  by 
veins -which  form  a  large  plexus— the  pampiniform  plexus. 
The  vessels  from  this  form  the  ovarian  veins  and  the  ovarian 
veins  empty,  the  left  into  the  renal;  the  right,  into  the  inferior 
vena  cava. 

The  Lymphatics  of  the  Uterus. — The  lymphatics  of  the  uterus 
terminate  in  different  glands.  Those  from  the  cervix  empty 
into  the  hypogastric  glands;  those  from  the  uterus  into  the 
deep  lumbar  glands,  situated  in  front  of  the  aorta,  about 
the  level  of  the  kidney. 

The  nerves  of  the  uterus   are  derived  partly  from  the  third 


22 


NORMAL    PELVIC    ANATOMY 


and  fourth  sacra]  nerves,  but  chiefly  from  the  sympathetic 
nervous  system. 

The  Fallopian  tubes  are  two  convoluted  muscular  canals 
extending  from  the  uterine  cornua  through  the  upper  portion 
of  the  broad  ligaments.  They  are  12  to  14  cm.  long,  the  left 
being  shghtly  the  longer.  They  are  divided  into  the  uterine 
portion,  extending  from  the  cornu  to  the  upper  angle  of  the 


Pig.  3. — The  arteries  of  the  uterus  and  ovaries:  0,A.,  Ovarian  artery; 
b,  artery  of  the  round  Hgament;  b',  branch  to  the  tube;  c,  c,  c,  branches  to 
the  ovary;  d,  continuation  of  main  trunk;  e,  branch  to  the  cornu;  U.A.. 
uterine  artery;  e,  main  trunk;/,  bifurcation;  g,  vaginal  branches;  /;,  vaginal 
branch  from  the  cervical  artery.      (Hyrtl.) 


uterine  cavity;  the  isthmus,  the  narrow  portion  of  the  tube  ad- 
joining the  uterus;  the  ampulla,  or  wider  portion  of  the  tube, 
and  the  fimbriated  extremity  or  abdominal  opening.  These 
fimbria  are  exuberant  folds  of  the  lining  mucous  membrane, 
and  one  of  them — the  ovarian  fimbria — extends  nearly  or 
quite  to  the  ovary. 


THE     INTERNAL     GENERATIVE     ORGANS  23 

The  tube  is  composed  of  an  inner  mucous,  a  middle  muscular 
and  an  outer  peritoneal  layer.  The  lining  mucous  membrane 
is  composed  of  a  single  layer  of  high  columnar  ciliated  cells, 
resting  upon  a  thin  basement  membrane.  There  is  no  sub- 
mucosa.  The  mucosa  is  arranged  in  folds  which  vary  from  a 
comparatively  simple  arrangement  near  the  uterus  to  an  extra- 
ordinarily complex  one  near  the  abdominal  end.  The  cilia 
lash  towards  the  uterine  cavity. 

The  muscular  coat  is  composed  of  two  layers  of  non-striated 
muscle,  an  inner  circular  and  an  outer  longitudinal  one.  Some 
of  the  inner  fibers  run  longitudinally  also. 

The  caliber  of  the  tube  varies  from  the  uterine  end,  which 
will  admit  a  bristle,  to  the  ampulla  which  admits  a  fine  probe. 

The  Ovaries. — The  ovaries  are  two  almond  shaped  organs, 
slightly  flattened,  lying  against  a  small  depression  in  the  pos- 
terior surface  of  the  broad  ligament,  and  attached  to  the  liga- 
ment by  the  mesovarium.  The  ovary  is  of  a  mother  of  pearl 
color,  5  cm.  long,  3  cm.  broad  and  1.5  cm.  thick,  weighing 
about  8  grams.  The  hilus  of  the  ovary  is  that  portion  of  the 
margin  to  which  is  attached  the  mesovarium. 

The  external  appearance  of  the  ovary  varies  with  the  age  of 
the  woman.  In  young  women  its  surface  resembles  mother  of 
pearl,  through  which  show  a  number  of  small  vesicles— the 
graafian  follicles.  In  older  women  the  ovary  is  rough  and 
corrugated,  and  it  atrophies  rapidly  after  the  menopause. 
The  ovary  is  divided  into  the  medulla  or  central  portion, 
which  contains  the  blood-vessels,  and  the  cortex,  which 
contains  the  blood-vessels,  and  the  cortex  which  contains  the 
mature  and  immature  follicles.  The  blood-supply  of  the 
ovary  is  derived  from  branches  from  the  ovarian  artery. 
An  ordinary  Graafian  follicle  is  simply  a  connective  tissue 
space  in  the  cortex,  containing  a  highly  specialized  cell — the 
ovum — and  surrounded  by  a  wreath  of  capillary  blood-vessels. 
A  mature  Graafian  follicle  consists  of  a  connective  tissue 
covering — the  theca  folliculi — ;  an  epithelial  lining  and  the 
membrana  granulosa;  the  liquor  folliculi  and  the  ovum.     The 


24  NORMAL    PELVIC    ANATOMY 

ligaments  of  the  ovary  are  two  in  number,  the  utero-ovarian 
running  from  the  inner  side  of  the  hilus  to  the  uterus,  and 
the  infimdibulo pelvic,  a  thin  band  of  fascia  running  from 
the  outer  side  of  the  hilus,  just  under  the  top  of  the  broad 
ligament,  to  the  lateral  pelvic  fascia. 

The  pelvic  floor  is  composed  chiefly  of  the  levator  ani,  the 
transversus  perinei,  superficial  and  deep,  the  bulbocavernosus, 
the  anterior  and  posterior  triangular  ligaments,  the  coccygeus 
and  the  sphincter  ani  muscles.  The  levator  ani  is  far  the 
most  important.  It  consists  of  two  halves,  passing  back 
from  the  anterior  pelvic  wall  and  encircling  the  vagina  and 
rectum.  It  is  a  muscular  band  as  broad  as  the  first  two 
joints  of  the  index  finger,  and  is  the  chief  support  of  the 
rectum  and  posterior  vaginal  wall. 

The  deep  transversus  perinei  muscle  is  that  portion  of  the 
levator  ani  which  has  a  separate  sheath  and  is  inserted  in  the 
perineal  body  in  the  middle  line.  It  lies  between  the  super- 
ficial and  deep  perineal  fascias,  or  triangular  ligament.  The 
anterior  triangular  ligament  is  an  extension  of  Colles'  fascia. 

The  bulbocavernosus  muscles  are  in  the  labia  majora  and 
keep  the  labia  in  apposition. 

The  pelvic  floor  will  be  more  fully  discussed  in  the  Chapter 
on  Injuries  of  the  Birth  Canal  (Chapter  XII). 

The  lymphatics  of  the  perineum  and  lower  two-thirds  of  the 
vagina  empty  into  the  inguinal  glands  in  the  groin.  Those 
of  the  upper  one-third  of  the  vagina,  cervix  and  corpus  uteri 
go  as  already  described.  There  is  a  possible  metastasis  in 
cancer  of  the  fundus  uteri  to  the  groin,  along  the  round  liga- 
ment, which  does  not  exist  in  cancer  of  the  cervix. 


CHAPTER  II 

METHODS  OF  EXAMINATION.    OFFICE 
TREATMENT 

I.  History  Taking. — It  is  important  to  follow  a  definite 
plan  in  taking  the  history  of  any  patient,  and  especially  so 
in  gynecological  cases,  because  of  the  intimate  relation  of 
symptoms  from  the  pelvic  organs  to  those  of  the  general 
organism.  It  should  be  remembered,  however,  that  the 
patient's  recital  of  her  symptoms  is  likely  to  be  influenced  by 
her  nervous  condition,  and  no  attempt  should  be  made  to 
arrive  at  a  diagnosis  by  the  history  alone.  Its  value  is  partly 
relative  to  the  results  of  the  pelvic  and  abdominal  examina- 
tions. The  following  points  are  to  be  covered  routinely: 
I.  Age.  2.  Married  or  single.  3.  If  married,  how  many 
children;  how  many  living;  cause  of  death.  4.  Character 
of  pregnancies.  5.  Character  of  labors;  spontaneous;  long 
or*  short;  forceps?  Any  fever  during  convalescence?  6. 
Number  of  abortions  or  miscarriages,  and  at  what  date  o| 
pregnancy  they  occurred.  7.  Beginning  of  menstruation; 
interval;  pain  and  when  pain  is  most  marked;  duration  of 
flow;  amount  of  flow.  8.  Leukorrhea?  If  so,  amount? 
irritating  or  not?  color?  how  influenced  by  menstrual  flow? 
9.  If  menopause,  how  long  time,  and  whether  any  disagree- 
able symptoms  (hot  flashes,  nervousness,  irregular  bleeding). 
ID.  Have  the  patient  explain  symptoms  which  led  her  to  con- 
sult a  physician,  and  amplify  her  recital  by  questions  relevant 
to  the  complaints  (such  as  backache,  headache,  constipation, 
etc.).  Backache  is  one  of  the  most  common  symptoms  and 
should  always  be  asked  for.  11.  Family  history  as  regards 
tuberculosis,  carcinoma.  12.  Questions  regarding  previous 
treatment  or  operations,  particularly  the  latter.  13.  Pre- 
ss 


26 


METHODS  OF  EXAMINATION.      OFFICE  TREATMENT 


quency  of  urination;  amount  and  character  of  urine  passed. 
14.  Nervous  symptoms,  if  any,  such  as  depression,  irritability, 
worry,  sleeplessness,  etc. 

These  are  the  routine  questions  in  the  average  history; 
others  are  often  suggested  by  the  symptoms  which  caused  the 
patient  to  seek  relief. 

EXAMINATION  OF  PATIENT 

I.  Abdominal  examination  is  best  carried  out  with  the 
patient  flat  on  her  back,  with  knees  slightly  elevated,  to  relieve 


Pig.   4. — Palpation  of  the  abdomen.      (After  B.  C.  Hirst.) 

tenseness  of  the  abdominal  muscles.  The  corset  should  be 
removed,  all  clothing  loosened,  and  the  patient  so  draped 
with  sheets  that  there  is  no  unnecessary  exposure .  Unless 
the  bladder,  rectum  and  sigmoid  are  empty,  a  thorough  exami- 
nation cannot  be  made. 

The  routine  points  for  examination  are: 

I.  Elasticity  of  abdominal  wall.  2.  Diastasis  of  recti. 
3.   Both    kidneys    examined    for    position  and   mobility.     4. 


EXAMINATION    OF    PATIENT 


27 


Palpation  for  splanchnoptosis  and  points  of  tenderness.  The 
latter  particularly  over  the  appendix  and  both  groins.  5. 
Palpation  for  any  growth,  mass,  or  tumor.  6.  Percussion  of 
entire  abdomen,  to  note  gastroptosis,  dilated  stomach,  or 
dullness  from  growths  or  ascites.  7.  In  fat  subjects,  test 
thickness    of    abdominal    wall.     8.    In    abdominal    tumors, 


Pig.   5. — Points  of  tenderness  in  abdominal  examinations,  and  their  prob- 
able significance.      {After  Grossest.) 

mensuration  or  measuring  is  required  to  determine  their  rate 
of  growth.     The  diameters  measured  are: 

I.  The  greatest  girth  of  the  abdomen.  2.  The  distance 
from  ensiform  to  umbilicus.  3.  The  distance  from  umbilicus 
to  symphysis.  4.  The  distance  between  the  anterior  superior 
spines  of  the  iha.  5.  The  distance  between  the  anterior 
superior  spines  of  the  ilia  and  the  symphysis.     6.  The  distance 


28 


METHODS   OF  EXAMINATION.       OFFICE  TREATMENT 


between  the  anterior  superior  spines  of  the  iha  and  the 
umbilicus. 

Examination  of  the  pelvic  organs  by  palpation  is  carried 
out  in  one  of  the  following  positions : 

I,  The  dorsal  or  lithotomy  position  is  the  one  in  which  most 
examinations  are  made.  The  patient  is  arranged  on  the  table 
on  her  back,  with  her  hips  at  the  edge  of  the  table.     The 


Pig.  6. — Lines  for  mensuration,  to  determine  the  rate  of  growth  of  ab- 
dominal tumors.      {After  B.  C.  Hirst.) 

thighs  are  well  flexed  on  the  abdomen  and  the  legs  on  the 
thighs,  and  the  feet  are  supported  in  stirrups  or  other  suitable 
leg  supports.  The  patient  is  then  so  draped  in  a  sheet,  that 
only  the  mons  veneris,  external  genitalia  and  part  of  the 
buttocks  are  exposed,  avoiding  all  unnecessary  exposure. 
When  possible,  the  examination  is  made  with  the  index  and 
middle  fingers  of  the  left  hand  in  the  vagina,  and  the  right 
hand  is  used  for  counter  pressure  on  the  abdomen  (bimanual 


EXAMINATION    OF   PATIENT 


29 


examination).  It  is  often  necessary  to  use  only  one  finger, 
on  account  of  a  narrow  vaginal  canal,  and  in  this  case  the 
index  and  not  middle  finger  should  be  used.  In  virgins  vaginal 
examination  is  to  be  avoided  and  rectal  examination  substi- 
tuted. In  making  the  digital  examination  of  the  vagina,  care 
should  be  taken  to  avoid  pressure  on  the  region  around  the 
clitoris  and  vestibule,  causing  unnecessary  pain.  All  move- 
ments should  be  gentle,  and  the  use  of  rubber  gloves  for  all 
examinations  is  wise.     Glycerin,  glycerin  jelly  or  the  glycerin 


Pig.   7. — Patient  draped  for  vaginal  examination  in  the  dorsal  or  lithotomy 
position.      (After  B.  C.  Hirst.) 

base  unguents  dispensed  in  tubes  are  all  better  than  vaselin 
as  a  lubricant  for  the  examining  fingers. 

In  examining  for  tubes  and  ovaries,  the  hand  corresponding 
to  the  side  examined  must  be  used,  i.e.,  the  right  hand  for 
the  patient's  right  side,  and  the  left  hand  for  her  left.  Counter- 
pressure  with  the  free  hand  on  the  corresponding  groin  is 
required,  but  this  examination  is  only  satisfactory  when  the 
patient  is  thin  and  does  not  resist. 

2.  Rectal  examination  is  often  desirable  after  the  ordinary 


30  METHODS  OF  EXAMINATION.       OFFICE  TREATMENT 

bimanual  vaginal  examination,  as  the  patient  is  already 
in  position  for  it,  and  the  posterior  wall  of  the  uterus  and  the 
tubes  and  ovaries  can  often  be  felt  better  in  this  way.  Rectal 
examination  should  always  be  done  in  preference  to  vaginal 
examination  in  virgins.  The  forefinger  only,  protected  by  a 
glove,  is  inserted  to  its  full  length  in  the  rectum,  and  by  counter- 
pressure  on  the  abdomen  a  surprisingly  satisfactory  examina- 
tion can  be  made. 


Fig.   8. — Bimanual  examination  of  the  uterus.      (After  Kelly.) 

3.  Sims'  or  left  lateral  position  is  used  more  often  in  inspection 
of  the  cervix  and  local  treatment  to  the  cervix  and  vagina  than 
in  examinations.  The  patient  is  placed  on  her  left  side,  the 
left  leg  flexed  on  the  abdomen,  the  right  more  so  than  the  left 
and  falling  over  the  left  so  as  to  let  the  right  knee  touch  the 
table  on  which  she  is  lying.  When  the  perineum  is  retracted, 
the  vagina  is  distended  with  air,  the  uterus  falls  out  of  the 
pelvis,  and  any  method  of  local  treatment  is  thereby  facilitated. 
The  position  is  not  adapted  for  digital  examinations. 

4.  The  gemipectoral  or  knee-chest  position  has  the  same  ad- 


EXAMINATION    OF    PATIENT  3 1 

vantages,  though  to  a  greater  degree,  as  the  Sims'  position. 
It  is  not  adapted  for  digital  examinations.     The  patient  kneels 


Fig.   9.— .Patient  in  the  Sims  or  left  lateral  position.      (After  B.  C.  Hirst.) 

upon  the  table,  and  leans  forward  until  her  chest  touches 
the  table,  the  head  being  turned  to  one  side.     The  hips  are 


Fig     10. — Knee-chest   elevated  position.      (Ashton.) 

kept  as  high  as  possible,  and  the  thighs  must  be  perpendicular 
to  the  support  on  which  she  is  kneeling.     The  position  is 


32  METHODS  OF  EXAMINATION.       OFFICE  TREATMENT 

used  chiefly  in  local  treatments  of  the  cervix  and  posterior 
vaginal  vaults,  and  to  replace  a  retroverted  uterus. 

5.  The  erect  posture  for  examination  is  required  to  (i) 
determine  the  degree  of  uterine  prolapse,  which  may  be  masked 
as  the  patient  lies  on  her  back,  particularly  if  she  has  been  in 
bed  for  some  days;  (2)  to  determine  the  fit  of  a  pessary,  either 
for  retroversion  or  prolapse;  (3)  to  detect  injuries  to  the 
symphysis. 

The  patient  is  arranged,  standing  up,  with  her  skirts  pinned 
up  or  removed,  and  draped  in  a  sheet,  pinned  around  her 
waist  so  that  it  falls  to  the  ground,  and  the  edges  of  the  sheet 
overlap  in  front.  The  physician  kneels  facing  the  patient, 
his  hand  is  inserted  through  the  opening  between  the  two  edges 
of  the  sheet,  and  the  forefinger  passed  into  the  vagina.  The 
position  is  not  often  required,  but  is  useful  for  its  special 
indications. 

Examinations  under  anesthesia  are  required  in  the  following 
conditions : 

I.  In  young  girls.  2.  In  virgins  where  on  account  of  re- 
sistance rectal  examination  is  unsatisfactory.  3.  In  any 
patient  too  nervous  or  sensitive  to  permit  a  satisfactory 
examination.  4.  In  vaginismus.  5.  In  any  case  of  obscure 
diagnosis. 

The  best  anesthetic  is  chloroform,  which  gives  perfect 
relaxation,  and  has  a  minimum  of  unpleasant  after-effects. 
Only  a  very  small  amount  is  required,  as  the  anesthesia  is 
short.  Ether  is  unpleasant  to  take  and  more  likely  to  cause 
nausea.  Nitrous  oxid  and  oxygen  would  be  the  ideal  anes- 
thesia except  for  the  fact  that  sufficient  relaxation  is  often 
difficult  to  secure. 

Very  nervous  patients,  and  particularly  young  girls,  should 
be  anesthetized  in  bed,  and  not  be  arranged  in  position  for 
examination  until  completely  under  the  anesthetic.  In  this 
way,  they  have  no  unpleasant  memories  of  the  preliminary 
preparation  for  the  examination. 


EXAMINATION    OF   PATIENT 


33 


Aids  to  Diagnosis. — Specula. — The  specula  required  are: 
(i)  Sims',  (2)  some  form  of  bivalve  speculum  and  (3)  a 
skeleton  bivalve  speculum.  The  Sims'  speculum  is  most  useful 
in  its  original  form  of  a  single  instrument.  The  double  ended 
specula,  designed  to  provide  two  different  sized  specula  in  the 
one  handle,  are  often  somewhat  awkward  to  use.  The  spec- 
ulum is  inserted  edgewise,  with  the  handle  at  right  angles  to 
the  vertical  axis  of  the  vulvar  orifice,  and  then  turned  so  that 


Fig. 


II. — a,    Collin's   bivalve    speculum;  b,    Sims    speculum;  c,    wire 
valve  speculum,  for  exposure  of  the  cervix  and  vaginal  walls. 


bi- 


the  handle  is  directly  downward.  To  give  a  clear  view  of  the 
cervix,  when  the  Sims'  speculum  is  used  in  the  dorsal  position, 
a  retractor  for  the  anterior  vaginal  wall  is  required.  This  is 
not  necessary  in  the  Sims'  or  the  knee-chest  position. 

Bivalve  Speculum. — The  most  useful  form  is  the  Collin. 
Two  sizes  should  be  provided — for  nulliparous  and  multipar- 
ous  patients.  To  insert  the  speculum,  in  the  dorsal  position,  a 
digital  examination  is  made,  with  one  finger,  to  determine 
where  the  cervix  is.  The  vagina  does  not  run  straight,  in 
3 


34 


METHODS  OF  EXAMINATION.      OFFICE  TREATMENT 


but  downward  at  an  angle  of  forty-five  degrees  to  the  support 
on  which  the  patient  is  lying.     When  the  direction  of  the  cer- 


PiG.   12. — Sims'  speculum.      Blades  of  two  sizes  in  one  instrument. 

vix  is  found,  the  speculum  is  lubricated,  held  in  the  right 
hand,  with  its  blades  closed.     The  finger  used  to  find  the  cer- 


PiG.   13. — Bivalve  speculum  in  position  with  blades  open.      The  cervix 
appears  between  the  blades. 

vix  now  pulls  the  perineum  gently  downward.     The  speculum 
is  inserted  edgewise,  for  about  one- third  of  its  length;  is  then 


EXAMINATION    OF    PATIENT 


35 


turned  transversely  and  pushed  in  the  direction  of  the  cervix, 
downward  at  an  angle  of  forty-five  degrees.  When  inserted 
its  full  length,  the  blades  are  separated  and  the  cervix  should 
appear  between  them.  Very  commonly,  nothing  appears 
but  the  anterior  vaginal  wall.  This  means  that  the  angle  at 
which  the  speculum  has  been  inserted  is  not  steep  enough, 
and  the  blades  should  be  allowed  to  collapse,  the  speculum  is 
slightly  withdrawn,  re-inserted  at  a  steeper  angle,  and  the 
blades  reopened.  The  blades  can  then  be  held  open  by  a  set 
screw  provided  on  the  instrument,  and  as  this  type  of  speculum 


Fig.  14. — The  commonest  mistake  in  the  use  of  a  bivalve  speculum. 
The  instrument  has  been  inserted  at  too  slight  an  angle,  and  nothing  ex- 
cept the  anterior  vaginal  vault  appears  between  the  blades. 

is  self-retaining,  both  hands  of  the  physician  are  left  free  for 
the  necessary  treatments. 

In  removing  the  speculum,  it  is  withdrawn  for  about  an  inch, 
the  blades  are  allowed  to  collapse,  and  it  is  withdrawn,  turning 
it  edgewise  as  it  is  taken  out.  Unless  it  is  sHghtly  withdrawn 
before  allowing  the  blades  to  collapse,  the  cervix  is  pinched  and 
pulled  upon,  causing  avoidable  pain,  by  pulling  on  the  uterus 
and  broad  ligaments. 


36 


METHODS  OF  EXAMINATION.      OFFICE  TREATMENT 


The  skeleton  bivalve  speculum  is  used  in  precisely  the  same 
way  as  the  soHd  bladed  one.  Its  advantage  is  in  permitting 
appHcations  to  the  vaginal  walls,  which  are  of  course  covered 
by  the  soHd  bladed  instrument. 


Fig.  15.— B.  C. 
Hirst's  double  ten- 
acula  for  the  cervix. 


Fig.    16. — Thomas' 
uterine  dressing  forceps. 


Double  tenacula  or  "bullet  forceps"  are  sometimes  very 
useful  in  the  reposition  of  a  retroverted  uterus,  or  in  pulling 
down  the  uterus  to  make  examination  of  its  posterior  wall 
easier.  The  small  punctures  in  the  cervix,  caused  by  the 
teeth  of  the  instrument  are  negligible,  but  care  should  be  taken 


EXAMINATION    OF   PATIENT 


37 


to  use  a  model  with  sufficient  clearance  between  the  blades, 
so   that  the  cervix  is  not  pinched. 


■"iG.    17. — Emmet's 
curet  forceps. 


Fig.  18. — Simpson's 
uterine  sound. 


Uterine  dressing  forceps  are  of  two  types:  The  Thomas 
uterine  applicator,  a  narrow  bladed  instrument  used  for  appli- 
cations to  the  cervical  canal,  or  even  uterine  cavity,  and  the 


38  METHODS  OF  EXAMINATION.      OFFICE  TREATMENT 

Emmet   curetment   forceps  a   heavier  instrument,  to  be  used 
when  greater  sohdity  and  grip  are  required. 

A  uterine  repositor,  to  be  used  in  replacing  a  retroverted 
uterus,  is  a  kidney-shaped  ball  of  metal  on  a  long  handle. 
It  is  used  to  pry  the  uterus  forward,  assisted  by  a  double 
tenaculum  in  the  cervix,  with  the  patient  in  the  knee-chest 
position,  by  making  pressure  in  the  posterior  vaginal  vault. 
It  is  not  a  necessary  instrument,  as  a  pledget  of  cotton  held 
in  the  grasp  of  an  Emmett  curettement  forceps  makes  a 
more  efficient  one. 

The  uterine  sound  is  a  long  probe,  with  a  flat  handle  to 
secure  a  firm  grip,  graduated  from  o  to  9  inches  on  the  shank. 
It  has  been  used  to  determine  the  direction  and  length  of  the 
uterine  cavity,  but  is  fortunately  falling  more  and  more  into 
disuse.  The  less  the  uterine  cavity  is  invaded,  in  office  work, 
the  safer  the  patient.  When  the  sound  is  used  it  must  be 
inserted  by  sight,  through  a  bivalve  speculum,  and  after  the 
cervix  has  been  sponged  off  with  an  efficient  antiseptic  solution. 
It  should  never  be  inserted  by  sense  of  feel. 

Artificial  light  is  often  required.  Reflected  light  from  a 
head  mirror  is  difficult  to  control  and  focus.  Specula  provided 
with  electric  bulbs  on  the  blades  are  very  useful  as  long  as  the 
bulb  remains  clean  and  does  not  blow  out,  but  they  cannot  be 
boiled  with  the  bulbs  in  place.  The  best  light  is  an  electric 
headUght,  with  a  head  band  to  secure  it  in  place;  the  current 
either  from  the  street  circuit  or  a  battery. 

Sterilization  of  Instruments.- — All  instruments  must  be 
boiled  before  and  after  use.  Specula  must  be  warmed  before 
being  used,  if  they  have  cooled  after  sterilization,  as  the  touch 
of  cold  metal  is  unpleasant  to  most  patients. 

Oflfice  Equipment.- — Table. — A  table  permitting  the  dorsal, 
Sims',  knee-chest,  sitting  and  prone  positions  is  essential  for 
satisfactory  examinations.  A  most  satisfactory  one  has  a 
steel  frame,  adjustable  leg  supports  and  is  provided  with  a 
drainage  trough,  for  fluids  used  in  irrigating  and  douching. 
The  table  is  placed  where  a  good  horizontal  light  is  available. 


EXAMINATION    OF   PATIENT  39 

Vertical  light  from  a  skylight  without  horizontal  light  from  a 
window  is   useless. 

Sterilizers  should  be  provided  for  instruments,  dressings  and 
water.  Combination  sets  of  instrument,  dressing  and  water 
sterilizers,  are  the  most  practical  and  satisfactory. 

An  instrument  cabinet  is  most  useful,  but  not  essential. 
The  instruments  most  often  required  can  be  kept  in  the  in- 
strument sterlizer,  as  a  container,  and  used  from  there. 

Rubber  gloves  for  examinations  should  be  used  routinely. 
They  are  a  great  protection  to  both  physician  and  patient. 

Artificial  light,  concentrated  in  a  beam,  is  often  required  for 
inspection  of  the  cervix  through  a  speculum.  The  best  form 
is  a  headlight,  with  forehead  band,  fed  from  a  battery  or 
street  circuit.  A  pocket  flashlight  is  useful,  but  a  beam  re- 
flected from  a  head  mirror  is  not  satisfactory. 

Glass  jars,  to  contain  pessaries,  cotton,  tampons,  etc.,  and 
wide-mouthed  glass  bottles  for  solutions  such  as  nitrate  of 
silver,  boroglycerid,  ichthyol,  etc.,  are  essential. 

Office  Nurse. — It  is  most  desirable  that  the  physician  be 
assisted  in  his  examinations  by  a  nurse,  or  failing  this,  a  woman 
who  can  easily  be  trained  in  the  management  of  patients, 
sterilization  of  instruments  and  supplies  and  as  assistant  in 
offlce  treatments.  Such  an  arrangement  is  most  acceptable 
to  his  patients,  and  affords  protection  to  the  physician  himself. 

Instruments  required  have  already  been  listed  under  the  head 
of  "aids  to  diagnosis."  Other  supplies  needed  will  be  de- 
scribed under  "methods  of  local  treatment." 

Electricity  is  gaining  considerable  vogue  as  a  method  of 
office  treatment,  as  high  frequency,  galvanic,  f aradic  or  sinus- 
oidal current.  A  wall  cabinet  or  portable  apparatus  is  a  most 
useful,  though  a  somewhat  expensive  article  of  office  furniture. 

Gynecologic  examinations  in  private  houses  are  very  fre- 
quently required.  It  is  usually  necessary  to  examine  the 
patient  in  bed,  and  for  the  examination  she  is  arranged  across 
the  bed,  with  her  feet  on  two  chairs,  and  her  hips  over  the 
edge  of  the  bed.     The  chairs  are  arranged  facing  each  other, 


40 


METHODS  OF  EXAMINATION.      OFFICE  TREATMENT 


with  considerable  space  between  them,  to  give  the  physician 
ample  room  for  examination.  Should  a  table  be  required,  one 
can  be  improvised  out  of  a  kitchen  table,  with  the  top  suitably 
padded  by  a  blanket.  The  patient's  knees  are  held  back  by 
a  nurse,  or  can  be  secured  by  a  rolled  sheet,  tied  above  one 
knee,  passing  behind  the  patient's  back,  over  one  shoulder  and 
out  under  the  other,  and  tied  above  the  other  knee.     Whether 


Fig.   19. — Proper  way  to  arrange  a  patient  across  the  bed  for  vaginal 
examination.     Ther«  is  plenty  of  room,  and  the  chairs  are  out  of  the  way. 

she  is  in  the  dorsal  position  in  bed  or  on  the  table,  the  patient 
is  so  draped  in  a  sheet  that  unnecessary  exposure  is  avoided. 

For  abdominal  examination  the  patient  is  arranged  flat  on 
her  back,  with  the  abdomen  exposed,  but  a  sheet  covering  the 
lower  portion  of  the  body  and  a  second  sheet  or  large  towel 
covering  the  upper  portion,  so  that  only  the  abdomen  from 
the  costal  arch  to  the  upper  margin  of  the  pubic  hair  is  exposed. 
It  is  not  advisable  to  try  to  make  abdominal  examinations 
with  the  abdominal  surface  covered  by  a  sheet  or  towel.     The 


METHODS    OF    LOCAL    TREATMENT 


41 


two  greatest  problems  in  examinations  in  private  houses  are 
(i)  low  beds  and  (2)  poor  light.  The  first  can  be  overcome 
by  using  a  table,  though  the  bed  is  rarely  so  low  as  to  interfere 
much  with  examinations.  If  local  treatment  be  required, 
however,  a  table  is  much  better. 

Sufficient  light  may  be  had  by  a  pocket  flashhght,  or  head- 
light with  portable  battery,  or  by  having  a  lamp  held  by  a 
third  person.     In  emergencies  a  candle  with  a  large  polished 


Fig.  20. — Wrong  way  to  arrange  a  patient  across  the  bed  for  vaginal 
examination.  The  chairs  are  so  close  together  that  there  is  no  room  for 
examination. 

spoon  held  behind  it  as  a  reflector,  will  furnish  a  surprising 
amount  of  light. 


METHODS  OF  LOCAL  TREATMENT 

Tampons  are  made  of  wool;  wool  and  cotton;  or  all  cotton. 
Those  made  of  wool  are  decidedly,  the  best.  They  are  de- 
signed to  apply  solutions  or  powders  to  the  vaginal  vaults  and 


42  METHODS  OF  EXAMINATION.      OFFICE  TREATMENT 

retaining  them  in  place  for  any  desired  length  of  time,  usually 
twenty-four  to  thirty-six  hours.  Tampons  can  be  made  as 
required  by  taking  a  piece  of  wool  or  cotton  six  inches  by  three 
inches,  doubling  the  ends  in  past  the  middle,  so  that  they  over- 
lap, and  tying  a  piece  of  string  tightly  around  the  mass  at  the 
point  where  the  ends  overlap.  The  ends  of  the  string  are  left 
about  three  inches  long  and  tied  together  so  as  to  form  a  loop, 
by  which  the  tampon  can  be  removed  after  it  is  inserted.  A 
number  should  be  made  up  at  a  time,  sterilized,  and  kept  in  a 
glass  jar  with  dust-proof  top  till  required. 


Pig.  21. — A  wool  tampon. 

Uses. — Tampons  are  used  chiefly  in  the  follo'v\nng  condi- 
tions: (i)  Erosion  of  the  cervix;  (2)  moderate  pehdc  inflamma- 
tion, with  adhesions  but  without  a  palpable  mass;  (3)  adherent 
retroversion  of  the  uterus  (to  replace  by  constant  pressure); 
(4)  chronic  inflammation  of  the  cervix  and  vagina. 

Medication. — Any  solution  or  powder  may  be  used,  but  those 
in  most  common  use  are:  (i)  Boroglycerid  (a  25  per  cent,  or  50 
per  cent,  solution  of  boric  acid  in  glycerin)  probably  the  most 
useful  single  application;  (2)  ichthyol  and  glycerin,  in  the 
strength  of  60  per  cent,  ichthyol  and  40  per  cent,  glycerin; 

(3)  nitrate  of  silver,  in  strengths  of  4  per  cent,  to  10  per  cent.; 

(4)  boric  acid  powder;  (5)  tannic  acid  powder. 

In  using  these  medicaments,  it  must  be  remembered  that 
both  ichthyol  and  nitrate  of  silver  will  stain  the  patient's 


METHODS    OF    LOCAL    TREATMENT  43 

underclothes  indelibly,  particularly  if  an  excess  of  solution 
be  used. 

Insertion  of  Tampons. — The  patient  is  arranged  in  the  dorsal 
position,  and  a  Sims'  or  better  a  bivalve  speculum  is  inserted. 
A  tampon  is  grasped  in  a  pair  of  Emmet  curetment  forceps 
and  thoroughly  saturated  with  the  solution  to  be  used.  The 
tampon  is  inserted  in  the  vagina,  through  the  speculum,  and 
is  placed  with  moderate  pressure  against  the  cervix.  Two  or 
three  other  dry  tampons  are  inserted  below  it,  to  retain  the 
first  one  in  place.  They  are  held  in  place  as  the  speculum  is 
removed.  The  patient  is  told  how  many  have  been  used,  so  a 
corresponding  number  can  be  removed.  If  it  is  desired  to 
make  considerable  pressure,  as  in  a  case  of  adherent  retrover- 
sion of  the  uterus,  the  tampons  should  be  inserted  in  the  knee- 
chest  posture.  The  patient  herself  removes  the  tampons,  by 
the  loops  of  string  provided  for  the  purpose  on  each  tampon, 
at  the  designated  time. 

A  satisfactory  chronologic  arrangement  for  tampons  is  as 
follows:  The  patient  comes  to  the  office  Monday  morning  and 
the  tampons  are  inserted.  She  lemoves  them  Tuesday  morn- 
ing, takes  a  douche  Tuesday  morning  and  evening,  and  Wednes- 
day morning.  On  Wednesday  morning,  she  comes  to  the  office 
for  a  fresh  supply,  which  she  removes  Thursday  morning.  She 
takes  a  douche  Thursday  morning  and  evening,  and  Friday 
morning.  On  Friday  morning  she  comes  to  the  office  for  a 
fresh  supply.  She  removes  these  on  Saturday  morning,  takes 
a  douche  Saturday  morning  and  evening,  Sunday  morning  and 
evening  and  on  Monday  morning  begins  the  routine  again. 
Usually  a  course  of  tampon  treatment  should  last  three  to  four 
weeks. 

Local  applications  are  best  made  through  a  bivalve  or 
Ferguson  cylindrical  speculum.  Two  methods  are  available. 
The  solution  to  be  used  can  be  poured  in  the  speculum  until 
the  cervix  is  covered,  and  the  speculum  then  withdrawn  slowly 
so  as  to  bathe  the  vaginal  walls  in  the  solution.  A  better 
and  less  wasteful  method  is  to  apply  the  solution  directly  to 


44  METHODS  OF  EXAMINATION.       OFEICE  TREATMENT 

the  points  desired  by  an  applicator  wrapped  with  cotton  or  a 
camel's  hair  brush,  through  a  skeleton  wire  bivalve  speculum. 

Indications. — (i)  Erosion  of  the  cervix;  (2)  ulcers  on  cervix 
or  vaginal  walls;  (3)  patches  of  acute  inflammation  of  cervix 
or  vaginal  walls;  (4)  diffuse  acute  or  chronic  inflammation 
of  cervix  or  vagina. 

The  most  useful  solutions  are:  (i)  Nitrate  of  silver  40  or 
60  grains  to  the  ounce — by  far  the  most  useful;  (2)  pure  car- 
bolic acid — neutralized  later  by  application  of  alcohol;  (3) 
tincture  of  iodin  5  per  cent,  or  7  per  cent.;  (4)  ichthyol,  either 
pure  or  diluted  equal  parts  with  glycerin. 

If  nitrate  of  silver  solution  is  used,  by  pouring  in  through 
speculum,  the  patient  will  often  complain  of  considerable 
burning.  This  can  be  relieved  by  a  douche  of  salt  solution 
(half  an  ounce  to  four  pints  of  water),  either  in  the  office  or 
after  she  has  returned  home, 

Counterirritation  to  the  vaginal  vaults  of  10  per  cent, 
tincture  of  iodin  is  in  common  use,  but  of  questionable  value. 
As  a  local  disinfectant,  in  cases  of  acute  gonorrhea  or  other 
infection,  it  has  merit,  but  as  a  palliative  of  tubal  and  pelvic 
inflammation  (the  purpose  for  which  it  is  usually  used),  it  is  of 
doubtful  value. 

Douching.  —  The  vaginal  douche  is  the  most  frequently  used 
of  all  methods  of  local  treatment. 

Uses. — (i)  As  a  cleansing  agent;  (2)  to  apply  antiseptics  or 
astringents  in  solution;  (3)  to  apply  heat. 

As  in  most  cases  the  patient  will  use  the  douche  herself,  and 
as  she  is  usually  uninstructed  in  its  use,  the  following  directions 
will  prove  useful. 

Directions  for  Taking  a  Douche. — i.  Always  in  the  recumbent 
posture,  preferably  in  a  bath  tub,  2.  Use  fountain  syringe 
and  never  a  forced  flow.  3,  Boil  syringe  and  nozzle,  and  use 
boiled  water.  4.  Use  only  mild  antiseptics,  such  as  boric  acid, 
10  grains  to  the  ounce;  permanganate  1-3000,  and  not  bi- 
chlorid  or  carbolic  acid.  5.  Have  water  comfortably  hot. 
Never  cold.     6.  Have  syringe  not  more  than  two  feet  above 


METHODS    OF    LOCAL    TREATMENT  45 

body.  7.  Control  flow,  so  that  four  quarts  will  take  fifteen 
minutes  to  flow  through.  8.  Use  nozzle  with  blind  end, 
and  opening  in  side.  9.  Do  not  use  hot  douche  just  before, 
during,  or  just  after  period. 

The  water  should  never  be  forced  in  by  a  bulb  or  pressure 
syringe.  If  the  stream  from  such  a  syringe  should  strike  the 
externa]  os,  water  and  leucoriheal  discharge  might  easily  be 
forced  in  the  uterine  cavity  and  thence  through  the  Fallopian 
tubes  into  the  peritoneal  cavity. 

Instillations. — In  chronic  cases,  where  there  has  been  a  long 
standing  infection,  gonorrheal  or  otherwise,  it  is  likely  to 
localize  in  Skene's  glands,  Bartholin's  glands,  the  cervical  canal 
or  the  endometrium.  It  can  only  be  reached  by  instillation 
of  antiseptic  solutions,  or  better  antiseptic  paste,  into  the 
affected  canals. 

Medication. — (i)  Nitrate  of  silver  40  to  60  grains  to  ounce; 
(2)  carbolic  acid  and  10  per  cent,  tincture  of  iodin,  equal 
parts;  (3)  ichthyol  and  glycerin,  equal  parts;  (4)  argentide 
paste  20  per  cent,  (much  the  best);  (5)  in  Skene's  glands, 
obliteration  by  the  electric  cautery. 

Chronic  infection  of  Skene's  or  Bartholin's  glands  can  be 
reached  by  instillation  with  a  hypodermic  syringe  with  blunted 
needle.  The  duct  of  the  affected  gland  is  recognized  by  the 
reddened  areola  around  it,  the  needle  inserted  in  the  duct  and 
the  whole  gland  injected. 

Cervical  and  intra-uterine  instillation  requires  a  Braun 
syringe,  merely  a  hypodermic  syringe  with  a  long  metal  nozzle. 

Technic. — i.  A  double  tenaculum,  bivalve  speculum  and 
a  Braun  syringe  and  nozzle  are  boiled. 

2.  The  patient  is  arranged  in  the  dorsal  position  and  the 
cervix  exposed  through  the  bivalve  speculum. 

3.  If  necessary,  though  usually  it  is  not,  the  anterior  lip  of 
the  cervix  is  caught  with  a  double  tenaculum. 

4.  The  cervix  is  sponged  off  with  i  per  cent,  formalin 
solution. 

5.  The  Braun  syringe  is  fiUed  and  the  nozzle  is  inserted  in 


46 


METHODS  OF  EXAMINATION.      OFFICE  TREATMENT 


the  cervical  canal:  the  internal  os  for  cervical  oi  to  the  fundus 
uteri  for  uterine  instillation. 

6.  The  contents  of  the  syringe  are  slowly 
expelled  as  the  syringe  is  being  wifhdrawn. 

This  method,  as  well  as  that  of  intra- 
uterine applications  (of  iodin  or  other  anti- 
septics) is  not  free  from  danger.  With  the 
precautions  as  indicated  above,  infection  is 
not  to  be  feared,  but  in  spite  of  all  care, 
certain  patients  will  suffer  severely  or  even 
alarmingly  from  uterine  colic,  with  \-iolent 
pain  and  severe  shock.  Should  such  an  acci- 
dent happen,  rest,  hot  water  bag  to  lower 
abdomen,  hypodermic  of  morphin  gr.  3^^  and 
atropin  gr.  ^  {50,  and  stimulation  are  required. 

Local  blood-letting  and  the  puncture  of 
Nabothian  cysts  are  methods  of  ofhce  treat- 
ment belonging  to  the  older  school  of  treat- 
ment, and  rapidly  falling  into  disuse. 

Irrigations  are  required  for  the  urethra, 
bladder,  and  occasionally  for  the  uterus. 

Urethral  irrigations  are  nearly  always  done 
for  urethritis  of  gonorrheal  origin,  especially 
the  urethritis  that  persists  after  the  destruc- 
tion, by  cautery,  of  Skene's  glands.  The 
best  instrument  is  Skene's  reflux  or  corru- 
gated catheter,  inserted  first  into  the  bladder 
and  then  pulled  back  so  that  the  tip  is  out- 
side the  grip  of  the  vesical  sphincter,  and 
urine  ceases  to  flow.  The  catheter  is  con- 
nected with  the  tube  of  a  fountain  syringe 
and  the  solution  (preferably  boracic  acid,  gr. 
X  to  oz.  i)  is  allowed  to  flow  through  the 
catheter  and  back  through  the  corrugations. 

Bladder  irrigation  is  required  for  chronic 
cvstitis  and  as  a  means  of  distention  in  con- 


FiG.      22. — 

Syringe  for  intra- 
uterine instilla- 
tions. Being  of 
metal  and  glass, 
it  is  sterilized  by 
boiling. 


METHODS    OF    LOCy\L    TREATMENT 


47 


tracted  bladder.  Boracic  acid  solution  (gr.  x  to  oz.  i)  is  the 
solution  used.  It  is  best  introduced  into  the  bladder  by  a 
rubber  catheter  connected  to  a  four-ounce  glass  or  metal 
funnel.  Four  or  eight  ounces  of  solution  are  introduced  at 
a  time,  and  then  allowed  to  flow  back  through  the  catheter 
and  funnel. 

Uterine  irrigation  is  rarely  indicated  in  office  work.  Con- 
siderable dilatation  of  the  cervix  is  required,  and  patients 
requiring  uterine  irrigation  are  usually  confined  to  bed.     The 


Pig.   23  — Pritsch-Bozemann  intra-uterine  douche:  L,  Inlet;  R,  outlet;   5, 

screw  junction. 


irrigation  is  given  by  means  of  a  Fritsch-Bozemann  intra- 
uterine douche  nozzle,  connected  to  a  fountain  syringe.  Not 
more  than  two  feet  elevation  of  the  douchebag  is  allowable. 
Sterile  water  or  weak  antiseptic  solutions  (such  as  boracic 
acid  gr.  x  to  oz.  i;  nitrate  of  silver  1-5000;  lysol  i  dram  to 
4  pints;  potassium  permanganate  1-3000)  should  be  used.  In 
all  irrigations,  the  temperature  of  the  solution  used  should  be 
iio°-ii5°F. 


CHAPTER  in 

ANOMALIES  OF  DEVELOPMENT,    HERMAPHRO- 
DITISM.   STERILITY 

Absence  of  genital  tract  is  rare,  but  possible  as  a  whole  or  in 
part.  If  the  entire  tract  is  absent  there  is  nothing  to  be  done 
in  the  way  of  treatment;  partial  absence,  as  of  the  vagina, 
usually  requires  extensive  plastic  work,  to  be  described  under 
the  heading  of  Atresia. 

Abnormalities  of  the  Hymen. — The  hymen  is  normally  a 
delicate  membrane  partially  occluding  the  vaginal  outlet,  with 
an  opening  in  which  the  tip  of  the  index  finger  may  be  inserted. 
Its  abnormalities  are: 

I.  Double  opening  (septate  hymen).  2.  Numerous  open- 
ings (cribriform  hymen).  3.  Dentated  (irregular  edges  of 
opening).  4.  Imperforate  hymen.  5.  Thickened  hymen, 
so  dense  as  to  resist  coitus. 

Occasionally  the  hymen  may  be  so  elastic  that  it  is  not  rup- 
tured by  coitus,  or  even  by  delivery  of  a  child.  Normally, 
however,  the  membrane  is  ruptured  by  coitus,  and  destroyed 
by  childbirth.  After  delivery,  the  hymen  is  represented  by 
small  irregular  tabs  of  tissue,  called  myrtiform  caruncles. 
A  hymen  occluding  the  vaginal  opening  or  so  dense  as  to  be  a 
barrier  to  coitus,  demands  excision  rather  than  incision.  It 
is  trimmed  away  with  scissors,  and  the  edges  of  the  linear 
wound  coapted  by  enough  sutures,  of  number  one  chromic 
catgut,  to  control  bleeding.  The  bleeding  from  rupture  of  the 
hymen  at  coitus  is  normally  negligible,  but  occasionally  it  is  so 
profuse  as  to  require  one  or  more  ligatures. 

The  Development  of  the  Genital  Tract  and  its  Anomalies. 
— At  the  end  of  the  fourth  week  in  embryonal  life,  the  Wolffian 
bodies  are  formed.     Two  weeks  later  the  genital  glands  cov- 


HERMAPHRODITISM.       STERILITY  49 

ered  with  "germinal  epithelium,"  appear  just  inside  the 
Wolffian  bodies.  Coincidently  there  appear  two  ducts,  out- 
side the  Wolffian  bodies — the  Miillerian  ducts.  The  ovaries 
are  developed  from  the  primary  genital  glands;  the  entire 
genital  tract,  to  the  vulvar  orifice,  is  developed  from  the 
Miillerian  ducts. 

The  Miillerian  ducts  are  at  first  solid,  and  only  from  the 
ninth  week  of  fetal  life  on  do  they  acquire  lumen.  The  vagina 
is  still  solid,  after  the  uterine  cavity  is  formed.  Malforma- 
tions of  the  genital  tract  result  from  either  atresia  of  one  or 
both  Miillerian  ducts  or  a  failure  of  fusion. 

About  the  fifth  month  of  fetal  life,  the  vaginal  portion  of  the 
uteruS' — the  cervix — is  formed.  The  fundus  of  the  uterus 
rounds  out,  and  the  double  cavity  disappears.  The  hymen  is 
formed  about  this  time.  The  development  of  glands  in  the 
endometrium  is  late,  those  of  the  cervix  developing  first,  but 
in  some  instances  the  glands  do  not  develop  before  the  tenth 
or  twelfth  year.  At  birth,  the  cervix  is  much  better  developed 
than  the  uterine  body.  The  retrogression  of  the  Wolffian 
body  and  ducts  begins  at  the  eighth  week  and  is  completed  at 
the  sixteenth  week  of  fetal  life.  The  remains  of  these  struc- 
tures persist  in  the  broad  ligament  as  the  parovarium. 

That  portion  of  the  Wolffian  duct  below  the  parovarium 
sometimes  persists  as  a  canal,  known  as  Gartner's  duct. 
Usually  only  short  segments  remain,  but  it  has  been  traced 
through  the  uterus,  anterior  vaginal  wall  to  an  opening  at  the 
hymen. 

Congenital  anomalies  of  the  uterus  are  due  to  atresia  of  one 
or  both  ducts  of  Miiller,  or  to  their  failure  of  fusion. 

I.  Uterus  didelphys— with  double  vagina.  2.  Uterus  du- 
plex bicornis,  with  double  or  septate  vagina.  3.  Uterus 
duplex  bicornis,  with  single  vagina.  4.  Uterus  bicornis  uni- 
collis.  5.  Uterus  unicornis — where  one  duct  has  atrophied. 
6.  Uterus  cordiformis  (heart  shaped).  7.  Uterus  incudi- 
formis  (flat  top,  like  an  anvil).  8.  Uterus  septus  (external  form 
of  uterus  normal,  but  cavity  divided).     9.    Uterus   subseptus 


50  ANOMALIES    OF   DEVELOPMENT 

(external  form  of  uterus  normal,  but  partial  septum  in  cavity. 
Normal  in  horse  and  ass).  lo.  Uterus  biforis  (cervix  di- 
vided by  a  septum — normal  in  the  ant-eater). ' 

Double  uteri  are  usually  asymmetrically  developed,  and  if 
pregnancy  occurs  it  is  usually  in  the  better  developed  half — 
repeated  pregnancies  occurring  in  the  same  half.  Pregnancy 
in  a  uterus  unicornis  is  usually  diagnosed  as  extra-uterine 
pregnancy,  and  the  true  condition  seen  only  at  opera- 
tion. If  the  opening  of  a  double  or  septate  uterus  is  closed, 
the  symptoms  and  treatment  are  those  of  atresia,  and  will  be 
described  under  that  head. 

Defects  of  Urethra  and  Bladder. — Hypospadias  in  the  female 
varies  from  minor  defects  in  the  urethra  to  complete  absence 
of  the  canal.  If  the  defect  is  complete,  the  vesical  sphincter 
is  also  absent,  and  operative  cure  is  impossible.  In  other  cases, 
the  defect  may  be  remedied,  with  fair  chance  of  success,  by 
plastic  operation  designed  to  fit  the  individual  case. 

Exstrophy  of  the  bladder  is  the  absence  of  the  anterior  wall 
of  the  bladder,  and  the  anterior  abdominal  wall  covering  it. 
In  the  upper  part  of  the  bladder  this  is  called  superior  vesical 
fissure;  in  the  lower  part,  inferior  vesical  fissure,  and  in  the 
urethra  and  vulva,  epispadias.  The  only  relief  is  by  plastic 
operation,  with  doubtful  success. 

Rectum. — The  rectum  may  be  imperforate.  In  which  case  it 
must  be  recognized  and  treated  immediately  after  birth. 
Atresia  of  the  anus  varies  from  a  thin  occluding  layer  of  super- 
ficial epithelium*  which  can  be  easily  perforated,  to  a  thick 
layer  of  fibrous  tissue  requiring  extensive  dissection.  The 
sphincter  ani  is  always  present,  so  complete  control  is  to  be 
expected  in  successful  operations. 

Occasionally  there  is  no  opening  at  the  anal  dimple,  but 
the  rectum  opens  in  the  vagina,  behind  the  vestibule.  This 
is  anus  vestibularis,  and  patients  with  this  defect  often  reach 
adult  life  without  knowledge  of  their  condition.  It  may  re- 
quire no  treatment,  but  if  operation  is  indicated,  the  rectal 
pouch  is  brought  down  to  an  opening  through  the  anal  dimple 


HERMAPHRODITISM.       STERILITY 


51 


and  sutured  there,  and  the  old  vestibular  opening  is  denuded 
and  closed.  Complete  control  is  the  rule,  as  the  sphincter  ani 
is  not  disturbed. 

Gjniatresia. — Atresia  of  the  genital  canal  may  be  congenital 
or  (more  rarely)  acquired;  it  may  be  comp'ete  from  the  cervix 
to  the  vulva,  or  may  involve  either  the  hymen,  vagina  or  cer- 
vix alone.  As  a  result  of  atresia  of  the  canal  the  menstrual 
blood  and  cervical  and  uterine  mucus  cannot  escape,  and 
gradually  accumulate.     Finally   the  vagina,   cervix,   uterine 


Fig.   24. — Hematocolpos,  hematometra,  and  hematosalpinx  caused  by  an 
imperforate  hymen.      (Ashion.) 

cavity  and  even  the  tubes  are  considerably  distended.  If  the 
blood  is  confined  to  the  vagina  alone,  the  condition  is  called 
hematocolpos;  if  the  uterus  alone,  hematometra,  if  the  vagina 
and  uterine  cavity  are  both  involved,  hematocolpometra  or 
hemelythrometra;  if  the  tubes  are  distended,  hematosalpinx. 
The  blood  is  very  thick,  dark  and  tarry,  and  is  extraordi- 
narily putrescible  when  once  exposed  to  the  air. 

Symptoms. — Rarely  if  ever  occur  before  puberty.     At  each 
menstrual  epoch,  there  are  marked  menstrual  molimina,  but 


52  ANOMALIES    OF   DEVELOPMENT 

no  flow.  The  patient  suffers  with  intense  cramp-hke  pains, 
and  usually  recognizes  herself  that  there  is  some  obstruction 
to  the  escape  of  the  menstrual  blood.  Gradually  there  develops 
enlargement  of  the  uterus,  which  can  be  felt  plainly  in  the* 
abdominal  cavity,  and  often  there  are  associated  symptoms 
of  pelvic  inflammation.  Usually  the  tumor  of  retained  blood 
is  so  well  marked  in  a  few  years  after  puberty  that  surgical 
intervention  is  obviously  needed. 

Diagnosis.— UsuaMy  by  attempt  at  vaginal  examination,  the 
point  of  atresia  is  at  once  located.  If  the  hymen,  it  can 
be  seen  to  be  imperforate  and  bulged  outward  as  soon  as  the 
labia  are  separated.  In  this  case,  the  vagina  is  first  distended 
and  only  after  considerable  delay  is  there  dilatation  of  the 
cervix  and  distention  of  first  the  cervical  canal  below  the 
internal  os.  This  gives  an  hour-glass  shape  to  the  uterus,  and 
by  rectal  examination  the  uterine  body  can  be  felt  on  top  of  a 
cystic  tumor.  If  the  atresia  is  cervical,  there  is  usually  a 
uniform  distention  of  the  uterine  cavity,  which  may  reach  very 
large  size,  thinning  out  the  uterine  walls  like  paper.  The 
presence  of  menstrual  molimina,  with  absence  of  flow;  the 
obvious  atresia  on  inspection  and  palpation  and  the  cystic 
tumor  should  make  the  diagnosis  easy. 

Prognosis. — Operative  interference  is  nearly  always  required, 
and  is  much  the  safest  plan.  Spontaneous  rupture  may  occur, 
either  into  the  peritoneal  cavity  or  through  the  vagina  or 
hymen.  Rupture  into  the  peritoneal  cavity  is  nearly  always 
fatal  from  peritonitis.  Spontaneous  rupture  through  the 
vagina  or  hymen  is  dangerous,  because  drainage  is  rarely 
complete,  the  retained  blood  suppurates  and  there  is  a  high 
mortality  from  sepsis. 

Treatment.- — -Before  any  local  measures  are  attempted,  the 
condition  of  the  Fallopian  tubes  must  be  determined  by 
rectal  examination  or  by  exploratory  section,  if  the  rectal 
examination  is  a  failure.  If  the  tubes  are  distended  they  must 
be  removed  as  the  first  step  in  the  operative  treatment,  be- 
cause of  the  danger  _^  from  peritonitis.     The  local  measures 


HERMAPHRODITISM.      STERILITY  53 

in  the  genital  canal  depend  upon  the  degree  of  atresia.  If 
the  hymen  alone  is  involved,  it  is  best  excised.  If  the  vagina 
is  closed,  a  large  urethral  sound  is  placed  in  the  urethra,  another 
in  the  rectum,  as  guides,  and  the  vagina  opened  between  them 
by  blunt  dissection.  If  the  cervix  is  involved,  a  crucial  incision 
is  made  over  the  site  of  the  external  os,  and  the  opening  thor- 
oughly dilated.  Then,  in  any  case,  the  accumulated  blood 
is  washed  out  by  persistent  irrigation  with  a  large  uterine 
catheter  and  hot  saline  solution,  until  the  fluid  returns  clear. 
Then  the  entire  canal,  or  as. much  of  it  as  was  dilated  by  the 
accumulated  blood  is  packed  with  iodoform  gauze,  renewed 
daily  until  the  canal  has  resumed  its  normal  proportions. 

Rudimentary  or  absent  vagina  is  usually  accompanied  by 
rudimentary  internal  genitalia,  so  that,  because  the  uterus  is 
functionless,  hematometra  does  not  occur.  These  individuals 
often  have  normal  sexual  instincts  and  in  case  of  marriage, 
an  artificial  vagina  may  have  to  be  made.  The  vaginal  canal 
is  made  by  blunt  dissection  and  lined  with  epithelium  from  the 
labia,  split  for  the  purpose.  A  more  dangerous  procedure, 
though  more  successful,  is  to  bring  down,  through  an  opening 
into  the  peritoneum,  a  resected  piece  of  small  intestine  with 
its  mesentery.  The  permanent  results  of  artificial  vagina, 
however,  are  most  disappointing;  the  vast  majority  contract 
to  a  narrow  sinus  or  close  altogether. 

Hjrpertrophy  of  the  Genital  Organs. — Hypertrophy  of  the 
labia  majora  is  rare,  except  as  syphilitic  elephantiasis.  The 
treatment,  if  any  be  required,  is  amputation. 

Hypertrophy  of  the  labia  minora  is  more  common,  especially 
in  certain  races  (Hottentots)  where  the  condition  is  deliberately 
produced  by  manipulation.  If  the  labia  are  inflamed,  or 
interfere  with  coitus,  they  are  excised. 

Hypertrophy  of  the  clitoris  is  common,  and  sometimes  extreme, 
reaching  a  length  of  three  to  four  inches.  If  it  causes  discom- 
fort, it  can  be  amputated,  but  amputation  for  nymphomania 
or  masturbation  is  useless. 


54  ANOMALIES    OF   DEVELOPMENT 

Hermaphroditism. — True  hermaphroditism,  where  the  indi- 
vidual possesses  completely  developed  and  functionating  ovarian 
and  testicular  tissue,  has  not  been  proven  in  the  human  being. 
The  true  sex  is  determined  by  the  genital  glands  (ovaries  or 
testicles),  and  not  by  external  characteristics. 

Pseudohermaphrodite  is  the  proper  name  for  the  human 
species.  They  are  either  male  or  female  pseudohermaphro- 
dites, according  to  which  set  of  glands  is  developed  and 
functionating. 

The  female  type  has  the  external  genitals  and  secondary 
sexual  characteristics  of  the  male,  but  has  ovarian  tissue  and  at 
least  a  rudimentary  uterus  internally.  This  type  is  the  rarer. 
The  male  type  has  obviously  feminine  characteristics,  but 
has  a  rudimentary  penis,  imperforate  urethra  or  hypospadias, 
a  shallow  pouch  resembling  a  vagina,  and  testicles  either  un- 
descended or  high  up  in  separate  scrotal  sacs,  the  scrotum  being 
cleft. 

The  individual  should  ordinarily  be  brought  up  and  educated 
according  to  which  sexual  characteristics  predominate;  but  in 
cases  of  doubt  "it"  should  be  educated  as  a  boy. 

Sterility. — May  be  either  primary — in  which  the  patient 
never  has  conceived,  or  secondary — where  one  or  more  preg- 
nancies have  been  followed  by  sterility. 

Causes. — In  at  least  40  per  cent,  of  cases,  the  fault  lies  with 
the  male.     In  the  female,  the  commonest  causes  are: 

I.  Anteflexion  of  the  uterus,  with  cervical  stenosis.  2. 
Pelvic  inflammation — endometritis  or  salpingitis.  3..  Retro- 
version of  the  uterus.  4.  Acquired  cervical  stenosis — the 
so-called  one-child  sterility;  usually  due  to  laceration, 
eversion  or  erosion.  5.  Congenital  ill-development  or 
atresia.  This  includes  infantilism  (arrested  development). 
6.  Vaginismus. 

It  is  not  always  possible  to  determine  a  cause  upon  exami- 
nation; though  the  influence  of  the  x-ray  on  both  testicles  and 
ovaries  of  those  exposed  to  its  effects  must  not  be  forgotten. 
There  is  also  a  relationship  between  adiposity  and  hypoplasia 


HERMAPHRODITISM.      STERILITY  55 

of  the  sexual  organs.  This  is  not  a  constant  factor,  but  it  seems 
to  be  true  that  very  fat  women  are  less  fertile. 

Treatment. — Before  any  treatment  of  the  wife  is  instituted, 
the  husband  should  be  examined  to  determine  his  power  of 
procreation.  Obvious  physical  vigor  does  not  necessarily 
mean  power  to  procreate.  If  the  husband  is  pronounced 
capable,  the  most  frequently  required  treatment  for  the  wife  is 
a  dilatation  and  curettage — for  anteflexion  and  stenosis.  This 
is  done  under  anesthesia,  branched  dilators  being  used  to  secure 
a  transverse  dilatation  of  one  inch.  Very  little  curettage  is 
done — only  at  each  cornu.  Excessive  or  frequently  repeated 
curettage  brings  about  a  superinvolution  of  the  uterus  which 
may  render  the  sterility  incurable.  Unless  some  means  is 
taken  to  maintain  the  dilatation,  it  is  rarely  efhcient. 

Stem  pessary  is  dangerous  and  liable  to  be  followed  by  infec- 
tion; the  same  may  be  said  of  the  Wylie  drain — -an  aluminum 
or  hard  rubber  plug  worn  in  the  uterus  for  several  weeks 
following  the  dilatation;  the  Schatz  metranoikter — preferably 
the  four-bladed  modification,  is  the  safest  procedure.  This  is 
left  in  place  for  twenty-four  hours,  is  then  removed  and  the 
uterus  washed  out.  Cases  of  atresia  are  managed  by  the 
proper  restoration  of  the  patency  of  the  canal;  retroversion — if 
not  adherent — -may  be  remedied  by  a  pessary  or  operation; 
pelvic  inflammation  requires  the  cure  of  the  endometritis  by 
intra-uterine  instillations  or  by  dilatation  and  curettage. 
Salpingitis  requires  abdominal  or  vaginal  section  to  inspect 
and  restore  the  patency  of  the  Fallopian  tubes — a  procedure 
of  doubtful  efficiency.  Lack  of  development — the  so-called 
infantile  uterus — requires  dilatation  without  curettage,  elec- 
trical stimulation  by  the  galvanic,  (negative  pole  to  uterine 
sound)  rapid  faradic  and  sinusoidal  current,  and  hypodermic 
injections — intramuscularly — •  of  i  mil  corpus  luteum  extract, 
or  whole  ovarian  extract,  given  daily  in  series  of  twelve 
doses,  with  an  interval  of  two  to  three  weeks  between  series. 

Sterility  of  long  standing  is  sometimes  relieved  spontane- 
ously and  without  treatment. 


S6 


ANOMALIES    OF   DEVELOPMENT 


Artificial    impregnation,    by    injection  of    semen    into    the 
uterine  cavity,  by  means  of  an  instillating  syringe,  has  been 


A 


%, 


Fig.  25. — Instruments  for  maintaining  dilatation  of  the  cervical  canal. 
I.  Sponge  tent,  expanding  by  the  absorption  of  moisture.  Impossible 
properly  to  sterilize.  2.  Tupelo  tent  of  porous  wood.  Open  to  same 
objection.  3.  Stem  pessary  of  hard  rubber.  4.  Wylie  drain.  5.  Schatz's 
two-bladed  metranoikter.  6,  B.  C.  Hirst's  four-bladed  modification  of 
the  Schatz, 

frequently  tried,  with  disappointing  results.  Only  very  few 
successes  are  recorded  and  there  is  considerable  risk  of  infec- 
tion, due  to  contamination  in  handling. 


CHAPTER  IV 
DISEASES  OF  THE  VULVA 

I.  Abscess  of  Bartholin's  Gland. — Cause. — ^Much  the 
commonest  cause  is  gonorrhea.  Infection  by  staphylococcus 
or  streptococcus  is  possible,   but  much  rarer. 

Kinds. — I.  Pseudo-abscess,  where  it  is  the  result  of  an  in- 
fection of  a  retention  cyst  of  the  gland.     2.  True  or  gonor- 


PiG.  26. — Abscess  of  Bartholin's  gland  or  vulvovaginal  abscess. 

rheal  abscess,  where  the  diplococci  have  reached  the  depths  of 
the  compound  racemose  gland  or  have  burrowed  under  the 
epithelium  of  the  duct.  Nearly  all  abscesses  of  the  gland  are 
of  this  type. 

Symptoms.— 1.  Pain,   usually  severe,  and  throbbing,  with 
difficulty  in  walking  or  sitting  down.     2,  Distention  of  the 

57 


58  DISEASES    OF    THE  VULVA 

labium  by  a  pear-shaped,  brawny  swelling,  the  base  downward, 
displacing  the  vulvar  cleft  to  one  side.  3.  Palpation  between 
thumb  and  forefinger  reveals  the  swelling  and  usually  fluctua- 
tion.    4.  Nearly  always  unilateral. 

Differential  diagnosis  from  a  simple  cyst  of  Bartholin's 
gland  is  easy.  The  cyst  is  similar  in  shape,  but  is  painless, 
not  indurated,  much  less  tense  and  free  from  any  evidence  of 
inflammation. 

Treatment. — i.  Opening  of  the  abscess  cavity,  and  swab- 
bing out  with  tincture  of  iodin  (7  percent.)  or  pure  carbolic  acid, 
allowing  the  cavity  to  fill  up  by  granulation.  2.  Excision 
of  the  whole  gland — much  the  better  treatment.  A  longi- 
tudinal incision  is  made  over  the  outer  edge  of  the  swelling, 
away  from  the  vulva.  The  tense  gland  is  dissected  out,  taking 
care  not  to  rupture  it,  if  possible.  There  is  always  an  escape 
of  pus  when  the  finger-like  process  in  the  vaginal  wall  is  cut, 
and  here  is  usually  the  only  bleeding  vessel.  This  vessel  is 
tied,  the  wound  closed  with  interrupted  silkwormgut  sutures, 
leaving  an  opening  at  the  lower  end  for  a  guttapercha  tissue 
drain.  Catgut  is  npt  a  satisfactory  suture  material,  as  it  is 
too  soon  absorbed.  The  drain  is  removed  in  four  days,  the 
sutures  in  ten. 

In  inflammation  of  Bartholin's  gland,  the  pre-abscess  stage, 
there  are  no  symptoms,  except  an  area  of  erosion  around  the 
mouth  of  the  duct — the  macule  of  Saenger.  This  is  almost 
pathognomonic  of  gonorrhea.  The  treatment  is  injection  of 
nitrate  of  silver  solution,  40  grains  to  the  ounce,  into  the  duct 
by  a  hypodermic  syringe  with  a  blunt  needle. 

2.  Abscess  of  Skene's  Glands.^ — These  glands,  situated  in 
the  floor  of  the  urethra,  are  inflamed  only  by  gonorrhea.  The 
mouths  of  the  ducts  are  usually  not  visible,  but  due  to  the 
eversion  of  the  urethral  orifice,  they  are  visible,  when  inflamed, 
as  two  red  spots  with  dark  centers.  By  pressure  on  the  ure- 
thra, a  drop  or  two  of  pus  can  be  made  to  exude. 

Treatment. — Destruction  of  the  duct  by  strong  antiseptic 
solutions  or  better  by  an  electric  cautery  needle.     Occasionally 


ACUTE    DERMATITIS    OF    LABIA    AND   PERINEUM 


59 


the  ducts  are  occluded,  and  the  pus  burrows  into  the  tissues 
of  the  anterior  vaginal  wall,  forming  a  swelHng  not  unlike  a 
cystocele  in  appearance,  but  brawny  and  indurated.  Pres- 
sure on  it  causes  pus  to  well  out  of  the  urethra.  Drainage 
is  better  secured  by  a  vaginal  opening  than  by  opening  through 
the  urethra. 

3.  Acute  Dermatitis  of  Labia  and  Perineum. — Causes. — (i) 
Irritating  leukorrhea;  (2)  lack  of  cleanHness;  (3)  transitory 


J   .^ 


Pig.  27. — Skene's  glands  or  tubules.     The  urethral  meatus  is  split  to  show 
their  location. 


at  each  menstrual  period;  (4)  may  occur  without  demonstrable 
cause. 

Symptoms. — (i)  The  patient  complains  of  severe  discomfort, 
and  says  she  is  severely  "chafed;"  (2)  on  inspection,  the  labia 
are  indurated,  very  sensitive,  skin  harsh  and  dry,  and  this 
condition  extends  for  some  distance  on  the  perineum  and  inner 
surface  of  thighs.  The  appearance  is  exactly  that  of  severe 
sunburn,  during  the  hyperemic  and  edematous  stage. 

Treatment. — (i)  Correction  of  whatever  cause  can  be  found; 
(2)  avoidance  of  soap  and  water  cleansing;  (3)  use  of  sterile 
olive   or   sweet   oil  for   cleansing;    (4)  local   application    of: 


6o  DISEASES    or    THE   VULVA 

I^  Acid  carbolic gr.  xlv 

Acid  boric 5  iss 

Pulv.  zinc  oxid   5iii 

Glycerin 5  i 

Aquas  camphoras q.  s.  ad  5  vi 

M.  Sig.     To  be  applied  frequently  with  absorbent  cotton. 

4.  Adherent  prepuce  of  clitoris  is  most  often  seen  in  children 
where  it  is  a  frequent  cause  of  irritation  and  masturbation. 
In  adult  life  it  is  a  source  of  discomfort  from  retention  of 
smegma. 

Diagnosis  is  easily  made  by  inspection,  the  prepuce  covering 
the  glans  as  a  hood,  and  being  impossible  to  retract. 

Treatment. — The  adhesions  are  easily  broken  up,  using  a 
small  metal  strabismus  hook.  The  prepuce  is  retracted  daily 
and  the  glans  oiled  to  prevent  reforming  of  the  adhesions.  If 
they  persistently  reform,  as  they  often  do,  circumcision  is 
the  only  cure. 

5!  Chancre  of  the  vulva  is  usually  situated  on  the  inner  sur- 
face of  the  labium.  It  is  similar  in  appearance  to  chancre 
elsewhere  and  is  usually  accompanied  by  mucous  patches  on 
the  labia  and  vagina,  and  often  by  flat  condylomata.  If  the 
infection  is  old,  however,  the  resemblance  to  epithelioma  is 
close,  and  may  require  microscopical  examiration. 

The  treatment  is  salvarsan,  with  iodids  and  mercury,  as  in 
any  case  of  syphilis. 

6.  Condylomata  or  venereal  warts  are  of  two  kinds:  (i) 
The  pointed,  which  are  due  to  dirt  or  gonorrhea;  (2)  the  flat, 
nearly  always  associated  with  mucous  patches,  and  due  to 
syphilis. 

Diagnosis. — The  pointed  condylomata  are  branched  papil- 
lomata,  occurring  in  patches,  over  the  labia  and  perineum. 
Occasionally,  most  often  in  pregnancy,  they  extend  in  the  vag- 
ina, even  up  to  and  on  the  cervix.  There  is  usually  a  serous 
discharge,  irritating,  and  partially  macerating  the  growths. 
In  pregnancy,  they  grow  enormously. 

Flat  condylomata  are  raised  flat  patches,  usually  three  or 


DYSPAREUNIA  6 1 

four  in  a  group,  occurring  on  the  inner  surfaces  of  the  labia 
and  around  the  anus.  They  are  usually  associated  with  mu- 
cous patches  and  other  constitutional  signs  of  syphihs. 

Treatment. — Pointed  warts  should  be  removed  by  excision 
and  suture  of  their  bases,  or  by  cautery,  if  they  are  peduncu- 
lated. Unless  very  extensive,  they  can  be  removed  under 
cocain,  but  never  under  ethyl  chlorid  spray  if  the  cautery  is 
used,  as  ethyl  chlorid  is  inflammable. 

Flat  condylomata  should  be  let  alone,  and  constitutional 
treatment  given  for  syphilis. 

7.  Cysts  of  the  labia  may  be  (i)  Bartholin's  gland;  (2) 
lymphatic  cysts;  (3)  sebaceous  cysts;  (4)  dermoid  cysts. 
They  are  all  better  dissected  out  than  incised  and 
drained.  They  are  usually,  except  those  of  Bartholin's  gland, 
pedunculated,  and  removal  is  easy. 

Solid  tumors  of  the  labia  are  either  (i)  lipoma;  (2)  fibroma 
or  (3)  sarcoma. 

8.  Dyspareunia  (painful  coitus)  while  not  a  disease  of  the 
vulva,  maybe  considered  here,  as  many  of  its  causes  are  located 
in  the  vulva  and  lower  vagina. 

Causes. — (i)  Rigid  hymen;  (2)  acute  inflammatory  condi- 
tions of  vulva,  vagina  or  urethra;  (3)  vaginismus;  (4)  hemor- 
rhoids; (5)  inflammation  or  infiltration  of  the  pelvic  connective 
tissue;  (6)  adherent  retroversion  of  the  uterus;  (7)  salpingitis. 

Symptoms  are  simply  pain  on  coitus,  the  site  of  pain  being 
either  at  the  vulvar  entrance,  or  high  up  in  the  pelvic  canal, 
in  the  cases  where  there  is  pelvic  inflammation  or  displace- 
ment of  the  uterus.  The  pain  varies  from  slight  discomfort 
to  one  of  such  severity  as  to  make  coitus  impossible. 

Treatment. — As  the  condition  is  not  a  primary  one,  but  al- 
ways a  symptom,  the  treatment  consists  in  removing  the 
cause.  A  thick  rigid  hymen  is  better  excised  than  incised; 
vaginismus  is  overcome  by  progressive  dilatation  with  Hegar's 
bougies  or  better  by  a  bivalve  speculum,  inserted  closed  and 
the  blades  then  widely  separated;  or  by  incision  of  the  lower 
two-thirds  of  the  levator  ani  on  each  side;  hemorrhoids  (a 


62  .        DISEASES    OF    THE  VULVA 

surprisingly  frequent  cause)  removed  by  cautery  or  ligature, 
and  any  inflammatory  process  treated  by  douches,  etc., 
depending  upon  its  nature. 

9.  Elephantiasis  is  usually  not  the  true  elephantiasis,  but 
a  hypertrophy  of  the  labia  due  most  often  to  syphilis.  Patho- 
logically, the  picture  is  one  of  connective-tissue  overgrowth 
with  wide  lymph  spaces.  The  growth  (except  in  true  elephan- 
tiasis, where  it  may  be  enormous)  is  moderate  in  size,  and  is 
most  often  accompanied  by  characteristic  mucous  patches. 
In  all  cases,  a  Wassermann  should  be  taken. 

Treatment. — Of  the  true  elephantiasis,  excision  is  the  only 
treatment.  The  operation  is  formidable,  the  bleeding  often 
excessive  and  difficult  to  control,  even  by  mass  ligatures. 
Syphilitic  elephantiasis  will  often  yield  to  mixed  treatment, 
salvarsan  or  neosalvarsan  and  in  many  cases  operation  can 
be  avoided.  Obstinate  cases  require  amputation  of  the  labia 
majora,  labia  minora  and  clitoris. 

10.  Epithelioma. — The  vulva  is  the  rarest  seat  of  carcinoma 
of  the  genital  organs.  It  occurs  most  often  after  fifty  years  of 
age.  The  growth  is  almost  always  squamous  epithelioma, 
and  the  most  common  point  of  origin  is  the  clitoris.  Adeno- 
carcinoma of  Bartholin's  or  Skene's  gland  is  possible,  but 
exceedingly  rare.  Early  and  extensive  metastasis  to  the 
inguinal  chain  of  glands  is  the  rule. 

Symptoms. — A  small  hard  nodule  appears  near  the  clitoris 
or  one  labium  majus,  and  quickly  ulcerates.  This  ulceration 
spreads  rapidly,  over  the  site  of  the  clitoris  down  both  labia 
majora,  and  later  into  the  vagina.  The  surface  of  the  ulcer 
is  friable,  bleeds  at  the  slightest  touch  and  exudes  a  very  foul, 
thin,  purulent  discharge.  In  the  early  stage  pain  is  slight  or 
absent;  later  the  pain  is  excruciating,  and  often  increased  by 
thrombophlebitis  of  one  or  both  legs. 

Diagnosis  should  be  easy,  even  in  the  early  stage.  In  all 
cases  a  piece  of  the  growth  resected  and  examined  micro- 
scopically will  establish  the  diagnosis. 

Treatment. — Early,  complete  and  radical  excision  offers  the 


INFLAMMATION    OF    THE   VULVA  63 

only  hope  of  cure,  and  at  best  a  poor  one.  The  inguinal 
glands  must  always  be  excised,  and  all  suspicious  tissue  re- 
moved. Many  cases  are  seen  too  late  for  operation,  because 
of  the  early  metastasis.  After  operation,  all  cases  should  be 
treated  by  a;-ray  or  radium,  and  the  percentage  of  recurrence 
is  very  high.  For  inoperable  cases  or  for  recurrence  after 
operation,  radium  offers  the  best  chance  of  relief. 

11.  Sarcoma  of  the  vulva  is  much  rarer  than  epithehoma. 
Its  point  of  origin  is  most  often  the  labium  minus  and  it  is 
most  often  melanotic.  Diagnosis  and  treatment  is  the  same 
as  epithelioma,  but  almost  invariably  it  returns  as  a  diffuse 
sarcomatosis.  Other  solid  tumors  of  the  vulva,  such  as  fi- 
broma or  lipoma,  are  rare.  They  are  found  almost  exclusively 
in  the  labia  majora,  and  frequently  pedunculated,  painless,  and 
demand  removal  because  of  the  discomfort  of  their  presence, 
or  more  particularly  because  of  their  tendency  to  mahgnant 
degeneration. 

12.  Inflammation  of  the  vulva  (vulvitis)  is  rare,  except  in 
children,  because  of  the  resistance  of  the  surface  epithelium 
to  infection.  In  children,  gonorrhea  is  the  most  common 
cause;  in  adults,  vulvitis  is  usually  secondary  to  inflammation 
higher  in  the  genital  tract,  is  the  result  of  irritating  dis- 
charge of  pus  or  urine,  or  is  due  to  trauma. 

Symptoms. — The  vulvar  mucosa,  especially  that  of  the  labia 
minora,  is  red  and  edematous.  There  is  marked  discomfort  in 
walking,  sitting  down,  or  in  handhng  the  parts.  There  is 
considerable  sero-purulent  discharge,  most  profuse  in  gonor- 
rheal cases.  In  the  acute  cases,  pain  is  the  most  marked  symp- 
tom; as  the  acute  stage  passes,  there  is  often  an  intolerable 
itching.  As  a  result  of  desquamation,  especially  in  children, 
adhesion  of  the  labia  is  a  common  complication. 

Treatment. — The  treatment  of  gonorrheal  vulvitis  is  given  in 
the  chapter  on  gonorrhea  in  general.  The  treatment  of  non- 
gonorrheal  vulvitis  is:  (i)  Cleanhness — the  best  cleansing 
solutions  being  either  boric  acid  solution  (grains  ten  to  one 
ounce)  or  ly sol,  half  a  dram  to  two  pints.     The  vulva  should 


64  DISEASES    OF    THE   VULVA 

be  thoroughly  cleansed  at  least  four  times  daily;  (2)  the 
treatment  of  any  cause  that  may  be  present,  such  as  an  irri- 
tating leukorrhea,  or  leakage  of  diabetic  urine,  or  urine  from  a 
fistula;  (3)  antiseptic  or  astringent  solutions  such  as: 
nitrate  of  silver,  grains  ten  to  one  ounce;  zinc  sulphate,  two 
drams  to  two  pints  of  water;  solution  of  formahn,  3:4  of  i  per 
cent. ; argyrol  solution  10  percent.;  or,  which  has  given  the  best 
results,  the  prescription  given  under  the  head  of  acute  derma- 
titis of  labia.  Vulvitis  in  the  adult  is  often  a  very  stubborn 
condition,  and  occasionally  persists  for  years.  If  the  labia 
show  a  tendency  to  adhere  along  their  inner  surfaces,  liberal 
use  of  boric  acid  ointment  on  the  abraded  surfaces  will  pre- 
vent their  adhesion. 

13.  Kraurosis  vulvae,  or  sclerosis  of  the  vulvar  skin,  is 
the  result  of  a  long-continued  irritation,  either  from  discharge 
or  pruritus.  The  skin  becomes  white,  hard  and  parchment 
like,  and  the  patient  suffers  severely  from  excessive  itching. 
No  local  treatment  has  been  of  any  avail.  Several  cures  have 
been  reported  from  the  use  of  ovarian  extract  (due  possibly 
to  improvement  of  the  circulation  of  the  external  genitals), 
by  mouth  5  grains  four  times  daily,  or  better  hypodermically 
as  the  whole  ovary  extract  (i  mil  representing  20  mg.  of 
ovary,  given  once  daily).  Amputation  of  the  external  genitalia 
is  not  satisfactory,  owing  to  the  frequent  recurrence  of  the 
itching  in  the  scar,  so  that  the  patient  is  just  as  uncomfortable 
as  before.  Resection  of  the  five  pairs  of  sensory  nerves  supply- 
ing the  vulva  is  the  best  surgical  treatment;  it  is  a  difficult 
and  tedious  dissection,  but  worth  while.  From  long-continued 
irritation,  epithelioma  is  a  frequent  sequel  of  both  kraurosis 
and  pruritus. 

14.  Lupus  vulvae  is  tubercular  ulceration  of  the  vulva  and 
is  rare.  It  occurs  most  often  in  the  decade  of  thirty  to  forty 
years  of  age,  and  is  supposed  to  be  secondary  to  tubercular 
focus  elsewhere,  and  rarely  primary.  The  ulcer  may  be  very 
extensive,  is  covered  by  a  gray  slough,  and  has  feebly  nourished 
granulation    tissue.     There    is    a    tendency    to  spontaneous 


PRURITUS    VULV^  65 

healing  in  the  older  portions  of  the  growth,  which  will  dis- 
tinguish it  from  cancer.  The  growth  has  a  marked  tendency 
to  involve  the  anterior  vaginal  wall  and  cause  vesicovaginal 
fistula.  A  positive  diagnosis  can  only  be  made  by  excision  of 
portions  of  the  growth  and  microscopical  examination. 

Treatment  is  the  same  as  lupus  elsewhere.  Curettage  of  the 
surface,  x-ray  for  fifteen  to  twenty  minutes  daily  or  Finsen 
light  for  one  hour  every  other  day,  a  small  area  being  treated 
at  a  time,  will  give  the  best  results.  If  the  ulcer  is  primary, 
prognosis  is  good,  though  the  cicatrix  will  be  extensive.  If 
it  is  associated  with  tuberculosis  elsewhere,  the  prognosis  is 
bad.  Vesicovaginal  fistulae  resulting  from  lupus  cannot  be 
closed,  and  any  attempt  at  repair  will  only  result  in  making 
the  fistula  larger. 

15.  Pruritus  vulvae,  characterized  by  an  intense  itching  of 
the  vulvar  and  perineal  skin,  usually  accompanied  by  sclerotic 
changes  in  the  skin,  but  not  infrequently  without  any  visible 
lesion.  It  is  a  forerunner  of  kraurosis,  and  these  two  must 
be  considered  different  stages  of  the  same  pathologic  process, 
there  being  no  marked  dividing  line  between  them. 

Causes. — (i)  Diabetes — the  skin  change  being  produced  by 
chemical  action  of  the  irritating  urine;  (2)  dirt  and  parasites; 
(3)  irritating  leukorrheal  discharge  from  gonorrhea,  sloughing 
polyps,  cancer  or  endocervicitis ;  (4)  senile  atrophy — post- 
menopause — of  the  vaginal  and  vulvar  mucosa;  (5)  partial 
atresia  of  the  vagina  or  cervix;  (6)  neurotic  cases,  where  no 
obvious  cause  can  be  assigned. 

Symptoms. — ^The  skin  is  at  first  reddened  and  thickened, 
and  there  is  intense  burning  and  itching.  The  skin  gradually 
becomes  paler  and  more  parchment-like,  and  numerous 
fissures  appear.  This  stage  progresses  until  kraurosis  develops. 
Many  cases  have  only  the  violent  itching,  without  demonstra- 
ble change  in  the  skin. 

Treatment. -^Vrmiixx?,  is  essentially  a  symptom,  and  the 
treatment  must  therefore  be  directed  toward  removing  the 
cause.  As  diabetes  is  the  commonest  cause,  the  urine  of  every 
s 


66  DISEASES    OF    THE   VULVA 

patient  should  be  at  once  examined  for  sugar;  and  the  patient 
put  upon  appropriate  treatment,  if  sugar  is  present.  The 
remedy  for  dirt  or  parasites  is  obvious — cleanliness  and  shaving 
of  the  pubic  hair,  followed  by  frequent  washing  with  watery 
solutions  of  tincture  of  green  soap  two  ounces  to  one  pint  of 
water,  and  sponging  with  lysol  solution  one  dram  to  one  pint 
of  water  will  give  the  quickest  result. 

Leukorrheal  discharge  is  controlled  by  removing  the  cause, 
if  one  can  be  found,  and  the  discharge  is  kept  from  contact  with 
the  vulvar  mucosa  by  vaginal  tampons  with  50  per  cent, 
ichthyol  or  boroglycerid  25  per  cent.  The  discharge  from 
senile  vaginitis  is  best  controlled  by  painting  the  vaginal 
mucosa  with  7  per  cent,  tincture  of  iodin. 

Partial  atresia  is  dilated  to  afford  freer  drainage,  the  dilata- 
tion being  repeated  at  intervals,  as  the  atresia  tends  to  recur. 

Local  applications  are  usually  disappointing  or  at  most  give 
temporary  relief.  Cocain  solution  i  to  10  per  cent.;  carbolic 
acid  \'2  of  I  per  cent,  to  2  per  cent,  solutions;  nitrate  of 
silver  40  grains  to  the  ounce;  menthol  in  stick  form;  ichthyol 
50  per  cent,  in  glycerin;  injection  of  the  sensory  nerves  with 
novocain  solution  3^^  of  i  per  cent.;  alcohol  95  per  cent,  with 
I  grain  of  bichlorid  of  mercury  to  the  ounce;  tincture  of  ham- 
amelis  full  strength;  formalin  i  per  cent,  are  the  ones  offering 
the  best  chance  of  relief,  but  none  of  them  can  be  depended 
upon  for  more  than  temporary  benefit.  The  author  has  found 
the  prescription  given  under  the  heading  of  acute  dermatitis 
of  the  vulva,   the   most  valuable  of  all  local  applications. 

The  diet  must  be  regulated;  all  highly  spiced  foods,  tea, 
coffee  and  alcohol  forbidden. 

X-ray  treatments  are  much  more  valuable,  and  give  a  high 
percentage  of  cures.  Radium  is  not  so  efiicient,  on  account 
of  the  wide  area  to  be  treated.  Ovarian  extract  gr.  v  four 
times  daily,  or  i  mil  hypodermically  of  the  soluble  extract 
of  whole  ovary,  given  once  daily  is  worth  a  trial. 

Surgical  Treatment.  — Ohstinsite  cases,  with  marked  skin 
changes,  or  those  of  the  neurotic  type  where  the  itching  per- 


URETHRAL    CARUNCLE  67 

sists,  although  no  demonstrable  lesion  exists,  will  not  yield  to 
any  form  of  local  application,  but  will  require  one  of  two 
surgical  procedures,  (i)  Vulvectomy  or  amputation  of  the 
external  genitalia.  This  is  unsatisfactory,  as  the  itching  often 
persists  in  its  former  intensity  in  the  scar,  and  the  patient 
is  just  as  wretched  as  before.  (2)  Resection  of  the  five  pairs 
of  sensory  nerves  supplying  the  vulva — (i)  genital  branch 
of  genitocrural;  (2)  ilio-inguinal ;  (3)  inferior  pudendal;  (4)  per- 
ineal branches  of  the  pudic;  (5)  dorsal  nerve  of  clitoris. 
Simple  section  of  the  nerves  is  not  enough;  as  long  a  piece  as 
possible  must  be  resected.  The  first  two  are  found  in  the 
inguinal  canal;  the  last  three  in  the  perineum — the  perineal 
incision  paralleling  the  descending  ramus  of  the  pubis.  The 
dissection  is  difficult  and  tedious,  but  the  results  justify  it. 

16.  Pudendal  hernia  is  analogous  to  scrotal  hernia  in  the 
male,  the  gut  or  omentum  descending  along  the  inguinal  canal 
into  the  labium. 

17.  Urethral  Caruncle.  Definition. — A  blood-red,  flattened, 
usually  pedunculated  tumor,  hanging  from  the  posterior  lip 
of  the  urethra.  The  pathological  picture  is  usually  angio- 
neuroma.  The  painless  type,  which  is  rare,  is  angioma  simplex, 
and  is  usually  sessile. 

Symptoms.— (1)  Agonizing  pain,  especially  on  urination. 
The  slightest  touch  is  unbearable.  (2)  Inspection  shows  the 
characteristic  growth  which  is  usually  single  and  pedunculated. 
The  sessile  painless  variety  gives  no  symptoms,  the  patient 
being  usually  unaware  of  its  existence  until  it  is  found  in  the 
course  of  a  vaginal  examination. 

Treatment.- — Excision  of  the  growth,  with  its  base,  under 
general  anesthesia,  and  preferably  with  the  cautery.  Removal 
under  local  anesthesia  is  not  as  satisfactory,  nor  is  the 
attempted  destruction  of  the  growth  with  the  electric  needle 
to  be  recommended.  Recurrence  is  common,  especially  after 
removal  under  local  anesthesia. 

The  sessile,  painless  type  need  not  be  removed,  unless  it 
shows  evidence  of  increasing  in  size. 


68  DISEASES    or   THE  VULVA 

1 8.  Urethral  prolapse  is  most  common  in  old  age,  and  due 
to  senile  atrophy  Moderate  cases  simulate  the  sessile  type 
of  urethral  caruncle,  and  are  simple  ectropion  or  eversion. 
Severe  cases  are  not  unlike  cancer  in  appearance,  especially  if 
thrombotic.  While  the  condition  is  most  common  in  advanced 
life,  it  may  occur  at  any  age. 

Moderate  cases  do  not  give  much  if  any  discomfort  and  re- 
quire no  treatment.  Severe  cases  require  removal  of  the 
prolapsed  mucosa,  after  the  manner  of  the  Whitehead  opera- 
tion for  hemorrhoids. 

19.  Varicose  veins  of  the  vulva  (varicocele)  are  usually 
negligible  except  in  pregnancy.  Then  they  may  form  a  con- 
siderable mass,  but  after  delivery  they  disappear  completely 
or  remain  simply  as  one  or  two  visibly  dilated  veins,  usually 
near  the  clitoris. 

Except  in  pregnancy,  they  rarely  give  symptoms  unless 
thrombosed. 

Diagnosis  is  easy.  Inspection  shows  the  tortuous  mass  of 
veins. 

Treatment. — Rest  in  bed,  knee-chest  posture  for  fifteen  to 
thirty  minutes  four  times  daily  and  moderate  pressure  with  a 
vulvar  pad  will  control  moderate  cases.  The  danger  is  sub- 
cutaneous or  open  rupture.  Subcutaneous  rupture  gives  a 
huge  hematoma;  open  rupture  causes  dangerous  and  even 
fatal  hemorrhage.  The  patient  should  be  instructed  how  to 
make  pressure  on  the  mass  of  veins,  in  the  event  of  rupture. 
The  bleeding  is  finally  controlled  by  undersewing  and  ligation 
of  the  veins.  A  hematoma  must  be  widely  opened,  to  give 
access  to  the  bleeding  points. 


CHAPTER  V 

DISEASES  OF  THE  VAGINA,  EXCLUDING  LACERA- 
TIONS AND  THEIR  CONSEQUENCES 

1.  Absence  of  the  vagina  is  rare.  Congenital  absence  is 
associated  with  rudimentary  internal  genital  organs,  and  the 
uterus  is  functionless.  Apparent  absence  may  be  the  result  of 
atresia  of  a  part  or  whole  of  the  vaginal  canal.  Congenital 
absence  gives  no  discomfort  and  patients  are  unaware  of  the 
condition,  until  the  absence  of  menstruation  causes  them  to 
seek  advice.  Atresia  of  the  vagina  with  apparent  absence  of 
the  canal  causes  retention  of  the  menstrual  blood  at  puberty, 
and  its  attendant  symptoms. 

Congenital  absence  of  the  vagina  requires  no  treatment, 
unless  the  patient  is  to  be  married  and  desires  the  formation  of 
an  artificial  vagina.  This  is  done  by  blunt  dissection  between 
the  bladder  and  rectum  to  the  depth  of  the  normaV vagina,  and 
the  raw  surfaces  are  covered  by  epithelium  turned  in  from  the 
labia  or  buttocks.  A  better,  but  more  dangerous  plan,  is  to 
bring  down  through  an  opening  in  the  peritoneal  cavity,  a 
resected  piece  of  small  intestine,  with  its  section  of  mesentery. 
Both  plans  are  difficult,  and  the  artificial  pouch  is  very 
likely  to  close,  in  spite  of  all  efforts  to  preserve  its  lumen. 

2.  Atresia  of  the  vagina,  congenital  and  acquired,  is  treated 
in  Chapter  III. 

3.  Carcinoma  of  the  vagina  is  rare,  as  a  primary  growth. 
Secondary  cancer  of  the  vagina  is  very  common,  being  meta- 
static from  the  uterus,  rectum  and  bladder  in  the  order  named. 

Primary  carcinoma  is  almost  always  squamous  epithehoma, 
but  very  rarely  may  be  adenocarcinoma  from  congenital  cysts 
or  gland  inclusions.  The  commonest  site  is  on  the  posterior 
vaginal  wall.  Chorionepithelioma  may  rarely  be  primary  in 
the  vagina;  usually  it  is  metastatic  from  the  uterus. 

69 


yo  DISEASES    OF    THE  VAGINA 

Secondary  carcinoma,  being  usually  metastatic  from  the 
cervix,  is  most  commonly  situated  in  the  upper  third  of  the 
vagina. 

Symptoms. — The  growth  is  at  first  a  circumscribed  nodule, 
surrounded  by  a  raised  indurated  ring.  The  area  spreads 
slowly,  ulceration  and  bleeding  occur  early,  and  a  foul  seropuru- 
lent  discharge  appears.  Any  doubt  as  to  the  nature  of  the 
growth  can  be  settled  by  excision  of  a  piece  and  microscopical 
examination. 

Prognosis  is  very  bad,  and  even  after  early  extirpation  recur- 
rences are  the  rule. 

Treatment. — If  the  case  is  seen  early  enough,  total  extirpa- 
tion of  the  uterus  and  vagina  is  required.  If  the  site  of  the 
growth  is  high  up,  the  extended  Wertheim  operation  is  the 
best.  If  the  growth  is  near  the  outlet,  the  lower  portion  of  the 
vagina  can  be  freed  from  below,  and  the  operation  completed 
by  abdominal  extirpation. 

If  the  rectum  is  involved,  it  also  must  be  removed  and  an 
artificial  anus  made  by  inguinal  colostomy. 

Metastasis. — In  the  lower  third  of  the  vagina,  the  direction 
of  metastasis  is  to  the  inguinal  glands,  rectum  and  bladder. 
In  the  upper  two-thirds,  metastasis  takes  place  to  the  cervix, 
rectum,  bladder,  deep  sacral,  lumbar  and  renal  glands;  and 
rarely  to  the  groin. 

Inoperable  cases  are  best  treated  by  radium.  X-ray  has 
proved  disappointing.  Pain,  which  is  often  severe,  must  be 
controlled  by  morphin  or  codein  hypodermically.  Most 
cases  are  seen  too  late  for  radical  operation.  Any  indurated 
vaginal  nodule,  especially  one  with  ulceration  of  its  surface, 
should  he  at  once  excised  and  examined  microscopically. 

4.  Condylomata  of  the  vagina  are  rare,  and  usually  associated 
with  vulvar  growths.  The  warts  are  pink,  covered  by  normal 
epithelium,  not  ulcerated,  do  not  bleed  when  touched  and  can 
be  differentiated  at  sight  from  carcinoma. 

Treatment  is  removal  by  ligature  or  cautery,  under  general 


FOREIGN   BODIES    IN    THE  VAGINA  7 1 

anesthesia.     They  do  not  tend  to  recur,  provided  the  patient 
keeps  herself  clean. 
.  5.  Cysts  of  the  vagina  are  of  three  kinds: 

1.  Cysts  of  Gartner'' s  duct,  found  in  the  anterior  vaginal 
wall.  They  are  thick- walled,  contain  a  thick  viscid  fluid. 
They  may  be  so  large  as  to  give  the  appearance  of  a  cystocele. 

2.  Lymphatic  cysts,  found  anywhere  on  the  vaginal  walls. 
They  are  thin-walled,  look  like  large  bHsters,  and  contain  a 
thin  serum. 

3.  Epithelial  cysts,  due  to  buried  epithelium  from  faulty 
denudation  in  a  plastic  operation.  These  are  at  the  introitus 
or  in  the  vaginal  sulci.  They  vary  in  size  from  a  pea  to  a  wal- 
nut and  contain  a  thick  sebaceous  creamy  fluid,  erroneously 
described  as  "pus."  These  cysts  usually  cause  discomfort, 
especially  those  at  the  introitus. 

Symptoms  are  usually  absent,  except  in  the  epithelial  kind, 
which  often  cause  pain,  especially  in  coitus. 

Diagnosis  is  usually  easy.  Cysts  of  Gartner's  duct  look  not 
unlike  cystocele,  but  do  not  bulge  on  straining.  Lymphatic 
cysts  and  epithelial  cysts  are  unmistakable. 

Treatment  is  operative.  Simple  puncture  is  enough  for  the 
lymphatic  cysts.  Epithelial  cysts  are  dissected  out  and  their 
bed  obhterated  by  one  or  two  sutures.  Gartner's  duct  cysts 
can  be  shelled  out  by  blunt  dissection,  if  they  are  small. 
There  is  some  danger  of  injury  to  the  bladder  or  urethra. 
The  larger  cysts  of  Gartner's  duct  often  extend  into  the  layers 
of  the  broad  ligament,  and  their  removal  is  a  formidable 
procedure. 

6.  Fistula,  including  anus  vestibularis,  are  described  in 
Chapter  XV. 

7.  Foreign  bodies  in  the  vagina  are  most  often  pessaries, 
inserted  and  forgotten.  Almost  any  object  of  suitable  size  has 
been  inserted  by  insane  women  or  masturbators.  A  forgotten 
pessary  is  likely  to  erode  its  way  into  the  bladder,  rectum  and 
vaginal  vaults.  In  any  case  of  foul  vaginal  discharge,  a  pes- 
sary or  other  foreign  body  must  be  sought  for  as  a  possible 


72  DISEASES    OF    THE   VAGINA 

cause.  In  such  a  case,  removal  of  the  offending  body  and 
astringent  douches  for  one  or  two  weeks  is  all  that  is  required, 
provided  the  bladder  or  rectum  have  not  been  injured. 

8.  Garrulitas  vaginae  is  the  audible  escape  of  gas  from  the 
vagina,  following  exertion  or  rapid  change  of  position.  The 
cause  is  incomplete  closure  of  the  introitus,  due  to  laceration 
of  the  deep  and  superficial  transversus  perinei  muscles,  and  the 
cure  is  a  plastic  operation. 

9.  Septum  formation  in  the  vagina,  dividing  the  canal  into 
two  partially  or  entirely  separate  canals,  is  not  uncommon. 
Septa  give  no  symptoms;  are  found  accidentally  in  gynecolog- 
ical examinations.  In  labor  they  are  commonly  torn  loose  at 
one  end,  and  can  then  be  ligated  and  amputated. 

10.  Tuberculosis  of  the  vagina  is  rare.  As  a  primary  condi- 
tion, it  is  seen  usually  in  children.  In  adults  it  is  secondary  to 
lupus  vulvae.  It  shows  itself  by  ragged  ulceration,  covered 
by  pale  edematous  granulations,  showing  some  tendency  to 
heal  at  the  edges,  and,  in  the  adult  form,  a  marked  tendency  to 
form  vesicovaginal  fistula. 

It  is  treated  by  a;-ray,  radium  or  Finsen  light.  Local  appli- 
cations have  no  effect.  Vesicovaginal  or  rectovaginal  fistulse 
due  to  tuberculosis  cannot  be  closed. 

11.  Tumors. — Fibromyomata  and  myomata  of  the  vagina 
are  rare.  They  arise  from  the  muscle  of  the  vaginal  wall. 
They  are  usually  small,  pedunculated,  and  are  especially  prone 
to  slough.  The  site  is  most  often  the  posterior  vaginal  wall. 
Their  commonest  degenerations  are  necrosis,  sloughing  and 
sarcoma. 

Treatment  is  removal,  which  is  usually  easy.  If  they  are 
diffuse  and  sessile,  they  may  require  extensive  dissection. 
This  type  is  usually  adenomyoma. 

12.  Vaginismus  is  the  name  given  to  a  spasm  of  the  levator 
ani  and  other  pelvic  floor  muscles,  provoked  by  attempts  at 
coitus,  examination  or  the  insertion  of  any  instrument  into 
the  vagina. 


VAGINISMUS  73 

True  vaginismus  is  that  due  entirely  to  psychic  reflex,  with- 
out any  exciting  cause. 

Pseudovaginismus  is  that  due  to  some  painful  affection  such 
as  urethral  caruncle,  rigid  hymen,  excessive  perineal  repair, 
vaginal  ulcers,  abscess  of  Bartholin's  glands,  etc.;  the  spasm 
disappearing  when  the  cause  is  removed. 

In  true  vaginismus  the  muscular  spasm  is  often  shown 
before  the  parts  are  actually  touched,  while  in  pseudovaginis- 
mus it  is  the  actual  contact  that  causes  the  spasm  and  the  lesion 
causing  it  is  usually  obvious.  In  the  former,  no  lesion  or 
cause  can  be  found. 

Diagnosis. — It  is  not  always  easy  to  differentiate  between 
true  and  false  vaginismus.  A  careful  digital  and  specular 
examination  of  the  genital  canal  is  necessary,  and  this  nearly 
always  calls  for  an  anesthetic.  The  cervix  is  examined  for 
erosion,  the  vaginal  vaults  for  the  induration  of  cellulitis,  the 
anterior  vaginal  walls  and  urethra  for  urethral  caruncles,  ab- 
scess of  Skene's  glands  and  suburethral  abscess,  the  posterior 
vaginal  walls  for  fissure;  the  introitus  for  rigid  hymen,  ab- 
scess of  Bartholin's  gland  or  vulvitis.  If  the  case  is  one  of 
pseudovaginismus,  the  exciting  cause  can  often  be  found  and 
removed  at  this  examination.  If  no  cause  can  be  found,  the 
case  can  be  classed  as  true  vaginismus.  Any  examination 
without  anesthesia  must  be  conducted  with  great  gentleness, 
as  undue  roughness  or  impatience  often  aggravates  the  trouble. 

Treatment. — If  there  is  an  obvious  cause,  the  removal  of 
the  offending  lesion  will  give  prompt  relief. 

In  true  vaginismus  one  of  several  plans  of  treatment  may 
be  required. 

I.  The  Walthard  method,  depending  upon  the  theory  of 
antagonism  of  the  abdominal  muscles  to  those  of  the  pelvis. 
By  causing  the  patient  to  strain  and  bear  down  strongly,  the 
muscles  of  the  perineum  are  deadened,  so  that  the  finger  can  be 
introduced  into  the  vagina,  and  the  patient,  realizing  that  no 
pain  was  caused,  loses  her  fear  of  being  hurt  and  the  vaginismus 


74  DISEASES    OF   THE  VAGINA 

disappears.     This  will  succeed  in  a  small  minority  of  patients, 
and  is  worth  a  trial. 

2.  Gradual  dilatation  of  the  vagina  by  means  of  a  bivalve 
speculum  introduced  and  the  blades  separated  as  widely  as 
possible,  until  the  pressure  is  uncomfortable.  A  better  plan 
is  the  use  of  Hegar's  graduated  bougies,  loaned  to  the  patient, 
who  inserts  daily  successive  sizes,  as  she  can  bear  the  increased 
pressure,  leaving  each  in  place,  in  the  vagina,  for  an  hour, 
while  she  rests  in  bed.  Usually  in  several  weeks  they  have 
secured  sufi&cient  dilatation,  so  that  they  are  no  longer 
needed. 

3.  Obstinate  cases  require  incision  of  the  perineal  body,  in 
the  middle  line,  half  way  to  the  anus,  and  also  incision  of  each 
sulcus  about  an  inch  in  depth,  so  that  the  appearance  is  that 
of  a  double  sulcus  tear  in  labor.  Sutures  are  then  inserted 
from  above  downward,  converting  the  Y-shaped  incision  into 
a  transverse  line,  and  causing  a  gaping  vulvar  orifice. 

4.  In  all  cases  of  true  and  pseudovaginismus,  ovarian 
extract,  either  by  mouth  gr.  v  four  times  a  day,  or  preferably 
hypodermically  i  mil  daily  for  24  doses,  is  of  distinct  value. 

13.  Vaginitis  (Colpitis) :  Inflammation  of  the  Vagina. — 
The  vagina,  considering  the  provocation  to  infection,  is  com- 
paratively immune  during  adult  life,  due  to  the  protection 
of  its  squamous  epithelium  covering  (really  a  modified  skin) 
and  to  the  acid  secretion  (lactic  acid,  secreted  by  Doderlein's 
bacillus)  that  inhibits  the  growth  of  many  pathogenic  bacteria. 
In  childhood  vaginitis,  especially  the  gonorrheal  type,  is  much 
more  common.  In  adult  life,  vaginitis  without  a  preliminary 
mechanical  or  chemical  injury  to  the  surface  epithelium,  is 
rare.  In  the  senile  type,  past  the  menopause,  it  occurs  in 
patches,  giving  the  characteristic  mottled  appearance. 

Kinds. — -(i)  Diffuse  granular,  most  common  in  gonorrhea; 
(2)  Senile — in  patches  varying  from  a  pinhead  to  one  or  two 
centimeters  in  width;  (3)  Mycotic — due  most  often  to  thrush 
fungus,  leptothrix  or  Otdiuni  albicans.  Diabetic  urine  dis- 
tinctly favors  the  growth  of  fungi.     (4)  Emphysematous,  with 


VAGINITIS  75 

formation  of  gas  vesicles  in  the  mucosa,  seen  most  often  in 
pregnancy.     (5)  Acute  septic,  seen  in  puerperal  infection. 

In  any  kind  of  vaginitis,  but  most  often  in  the  senile  type, 
desquamation  of  the  surface  may  occur,  and  possibly  cause 
adhesion  of  the  opposing  vaginal  surfaces.  In  this  way  are 
formed  most  of  the  partial  or  complete  atresias  of  the  vagina. 

Catises. — (i)  Gonorrhea — the  cause  of  most  cases  of  acute 
vaginitis;  (2)  senile  atrophy;  (3)  long-standing  irritating 
cervical  or  uterine  leukorrhea — causing  chemical  injury 
to  the  surface  epithelium;  (4)  neglected  pessaries  or  tampons — 
causing  mechanical  injury;  (5)  infectious  diseases  like  typhoid, 
small-pox  and  diphtheria;  (6)  puerperal  fever;  (7)  fungi  of 
various  kinds,  the  commonest  being  thrush,  leptothrix  and 
Oidimn  albicans;  (8)  prolapse  of  the  uterus,  causing  ulceration 
of  the  vaginal  mucosa  by  exposure  and  friction;  (9)  rarely, 
in  children,  wandering  thread-worms  from  rectum. 

Symptoms. — (i)  Leukorrhea  is  the  most  constant  symptom, 
varying  from  a  thin  serous  discharge  to  a  thick  creamy  puru- 
lent and  very  profuse  flow.  (2)  Pruritus,  probably  chemical 
in  origin,  from  the  irritation  of  the  discharge.  (3)  Moderate 
burning  pain  (in  the  acute  cases  only)  referred  deep  into  the 
pelvis.  Certain  varieties  show  special  symptoms.  In  acute 
granular  vaginitis  the  vaginal  mucosa  appears  to  have  been 
dusted  with  large  granules  of  red  pepper  and  the  discharge  is 
profuse  and  creamy.  This  is  almost  certainly  gonorrheal. 
In  senile  vaginitis,  the  mucosa  is  mottled,  areas  of  redness 
contrasting  with  normal  mucosa,  and  often,  in  the  upper  third, 
there  are  adhesions  of  the  opposing  surfaces. 

Puerperal  vaginitis  is  usually  streptococcic,  and  produces  a 
thick,  greenish  yellow  false  membrane.  Diphtheritic  false  mem- 
brane is  dirty  gray.  Fungi  usually  grow  in  white  patches, 
easily  wiped  off,  and  leaving  a  bleeding  surface  behind.  The 
thick  leathery  mucosa  and  wide  patches  of  ulceration  seen  in 
prolapse  are  unmistakable. 

Diagnosis. — The  best  view  of  the  entire  vaginal  canal  is 
given  by  the  wire  Ferguson  bivalve  speculum.     The  blades 


76  DISEASES    OF    THE  VAGINA 

do  not  cover  the  vaginal  walls,  and  it  is  the  best  instrument  for 
both  diagnosis  and  for  making  local  applications.  Smears 
for  microscopical  examination  can  be  taken  from  any  portion 
of  the  canal. 

Treatment  varies  with  the  kind  of  inflammation.  Acute 
gonorrheal  vaginitis  requires:  (i)  Rest  in  bed;  (2)  milk  diet; 
(3)  large  amounts  of  water  (12  to  15  glasses  daily) ;  (4)  twice  daily 
a  thorough  vaginal  douche  with  a  hot  1-2000  permanganate 
of  potassium  solution  (4  quarts  during  a  period  of  15  minutes) 
followed  by  2  quarts  of  hot  sterile  water;  (5)  through  a  skele- 
ton speculum,  the  entire  vagina  is  painted,  with  pledgets 
of  cotton  on  an  applicator,  with  25  per  cent,  argyrol  or  i  per 
cent,  nitrate  of  silver  solution;  (6)  a  tampon  soaked  with  50 
per  cent,  ichthyol  in  glycerin  or  25  per  cent,  boroglycerid  is 
inserted,  to  remain  until  the  next  treatment.  (7)  If  the  vaginal 
mucosa  is  not  markedly  sensitive,  douches  of  acetate  of  lead 
2  per  cent. ,  or  pyroligneous  acid,  4  drams  to  the  quart  are  of 
value.  (8)  Between  treatments,  the  patient  wears  a  sterile 
vulvar  pad,  thickly  dusted  with  boric  acid. 

If  the  vaginitis  has  persisted  for  a  considerable  time  or  if 
the  above-described  treatment  does  not  subdue  the  infection 
in  ten  or  fourteen  daj^s,  the  vagina  is  bathed  in  a  40  grains  to  the 
ounce  (8  per  cent.)  solution  of  silver  nitrate,  poured  in  through 
a  bivalve  or  cylindrical  speculum,  and  the  instrument  slowly 
withdrawn,  to  smooth  out  the  folds  of  the  mucosa.  This  is 
followed  by  a  douche  of  normal  salt  solution,  to  convert  the 
nitrate  of  silver  into  the  insoluble  chlorid.  The  application 
is  repeated  every  other  day.  If  two  or  three  such  applications 
do  not  effect  a  cure,  the  vagina  is  wiped  out,  through  a  skeleton 
bivalve  speculum,  with  equal  parts  of  glycerin  and  carbolic 
acid,  followed  immediately  by  a  douche  of  50  per  cent,  alcohol. 
The  buttocks  and  labia  should  be  thickly  coated  with  vaselin 
before  carbolic  acid  is  applied. 

Chronic  vaginitis  yields  best  to  astringent  douches,  such  as 
the  following: 


VARICES    OF  THE  VAGINA  77 

Acid  carbolic 2  drams 

Acid  boric i  ounce 

Zinc  sulphat i  ounce 

Alum,  exsiccat 3  ounces 

M.  Sig.  2  teaspoonfuls  to  2  quarts  of  hot  water,  twice  daily.  Dis- 
solve the  powder  before  adding  it  to  the  douche  water. 

A  course  of  vaginal  tampons  of  50  per  cent,  ichthyol  or  25  per 
cent,  boroglycerid,  as  described  in  the  section  on  office  treat- 
ment, with  the  above  douche  in  the  intervals  is  the  most  satis- 
factory treatment. 

Senile  vaginitis  is  best  treated  by  (i)  suppositories  of  glycerin 
with  thymol  (5  per  cent.)  or  eucalyptol  (gr.  5)  or  iodoform  (gr. 
5)  inserted  at  bedtime  and  followed  in  the  morning  by  a  douche 
of  boric  acid  (two  ounces  to  the  quart).  If  this  does  not  give 
prompt  relief,  paint  the  entire  vaginal  mucosa,  through  a 
skeleton  speculum  with  7  per  cent,  tincture  of  iodin. 

Emphysematous  colpitis  responds  to  puncture  of  the  vesicles, 
which  do  not  refill,  and  boric  acid  douches,  twice  daily.  All 
forms  of  mycotic  colpitis  (thrush,  etc.)  respond  promptly  to 
boric  acid  douches,  after  the  mycotic  patches  have  been 
wiped  off  with  gauze. 

In  any  case,  the  entire  genital  tract  should  be  searched  for 
any  cause  (endometritis,  abscess  of  Skene's  or  Bartholin's 
glands,  endocervicitis)  which  might  be  the  primary  source  of 
the  irritant  which  keeps  alive  the  vaginal  inflammation. 

Prognosis. — In  all  cases  except  the  gonorrheal,  the  prognosis 
is  good.  Gonorrheal  cases  are  often  most  obstinate  and 
recur  after  apparent  cure,  due  to  latent  infection  in  Skene's 
or  Bartholin's  glands,  the  cervix  or  endometrium.  In  these 
cases,  Skene's  glands  must  be  obliterated,  Bartholin's  dissected 
out,  the  uterine  cavity  disinfected,  after  dilatation  of  the  cer- 
vix, by  iodin  and  carbolic  acid,  equal  parts,  and  often  the 
cervix  must  be  amputated,  before  even  a  relative  cure  can 
be  obtained. 

14.  Varices  of  the  vagina  are  rarely  seen  except  in  pregnancy 
and  may  then  reach  large  size,  with  considerable  danger  of 
serious  bleeding. 


CHAPTER  VI 

ABNORMALITIES  OF  THE  CERVIX,  EXCLUD- 
ING TEARS 

Normal  Anatomy  and  Relations. — The  cervix  or  neck  of  the 
uterus  is  that  portion  extending  from  the  internal  os  (or  lower 
border  of  the  lower  uterine  segment)  to  the  external  os.  The 
vaginal  portion  (about  3^-^  of  the  total  length)  projects  like  a 
nipple  into  the  vagina.  The  hps  of  the  cervix,  anterior  and 
posterior,  are  separated  by  the  external  os.  The  supravaginal 
(and  longer)  portion  of  the  cervix  extends  from  the  point  of 


a  b  c 

Pig.  28. — a,  NuUiparous  cervix,  with  circular  os  uteri ;  b,  nulliparous  cervix, 
with  transverse  os;  c,  multiparotis  cervix,  without  laceration. 

attachment  of  the  vaginal  mucosa  to  the  internal  os.  Anterior 
to  this  portion  is  the  bladder  and  vesico-uterine  pouch  of 
peritoneum;  posteriorly  lies  the  rectum  and  Douglas'  pouch. 
The  ureters  lie  close  to  this  portion  of  the  cervix;  nearer  the 
anterior  half.  The  left  ureter  is  much  closer  than  the  right, 
and  the  more  the  cervix  is  prolapsed  or  pulled  down,  the  nearer 
are  the  ureters  to  it.  This  is  a  point  to  be  remembered  in 
vaginal  hysterectomy. 

The  shape  of  the  cervix  in  a  nullipara  is  conical;  in  a  multip- 
ara, cylindrical, 

78 


ABNORMALITIES  OF  THE  CERVIX  79 

The  external  os  in  a  nullipara  is  circular  or  more  often  oval; 
in  a  multipara  (whose  cervix  is  not  torn)  it  is  a  transverse  slit. 
In  both,  the  canal  is  normally  closed  by  a  plug  of  thick  tena- 
cious clear  mucus — the  corpus  mucosum.  The  shape  of  the 
cervical  canal  is  spindle — narrowest  portions  at  either  os,  and 
the  broadest  in  the  middle. 

The  mucosa  of  the  vaginal  portion  is  squamous  epithelium 
and  is  normally  pale  pink.  The  mucosa  of  the  cervical  canal  is 
grayish  red,  soft,  cylindrical  epithelium,  with  long  slender 
ciliated  cells  with  the  nuclei  at  their  bases.  There  is  no  sub- 
mucosa.  On  the  anterior  and  posterior  walls  of  the  cervical 
canal,  the  mucosa  shows  transverse  folds,  like  the  ribs  of  a 
leaf — the  arbor  vUcb  or  palmcB  plicatcB. 

The  glands  of  the  cervix  are  tubular,  usually  much  con- 
voluted, and  extend  deeply  into  the  muscle. 

Methods  of  Examination  of  the  Cervix.^ — i.  Digital  examina- 
tion, misleading  in  its  results,  and  never  solely  to  be  depended 
upon. 

2.  Sims'  speculum  in  either  the  dorsal  or  Sims'  (left  lateral) 
position,  requiring  a  retractor  to  elevate  the  anterior  vaginal 
wall  as  well. 

3.  Bivalve  specuhmi  (duck-bill)  used  in  the  manner  de- 
scribed in  the  chapter  on  routine  office  treatment  (Chapter  II). 
This  is  much  the  best  plan. 

ABNORMALITIES  OF  THE  CERVIX 
Atresia  of  the  Cervix 

Atresia  of  the  cervix  is  (i)  congenital  or  (2)  acquired. 
Congenital  atresia  is  discovered  only  after  puberty,  when  the 
menstrual  blood  is  retained. 

Symptoms. — (i)  Severe  menstrual  molimina,  without  flow; 
(2)  increasing  pain;  (3)  a  spherical  cystic  tumor  in  the 
pelvis;  (4)  specular  examination  demonstrates  the  closure  of 
the  canal. 

Acquired  atresia  results  from:     (i)  Ulceration  of  the  cervix 


8o  ABNORMALITIES  OF  THE  CER\TX,  EXCLUDING  TEARS 

— from  injury,  sepsis,  malignant  growths  or  the  apphcation  of 
strong  caustics  in  the  canal;  (2)  cicatrization  following 
repair  or  amputation  of  the  cervix. 

Symptoms  are  about  the  same  as  in  the  congenital  variety, 
except  that  in  the  former  the  menstrual  flow  has  never  ap- 
peared. The  treatment  of  both  is  given  in  detail  under  the 
heading  of  gynatresia  in  Chapter  III. 

Atrophy  or  Subinvolution 

Atrophy  or  superinvolution  is  a  part  of  the  same  process 
in  the  uterus,  and  any  symptoms  proceed  from  the  latter. 
The  cervix  is  exceedingly  small,  and  presents  in  miniature 
the  features  of  a  normal  cer\dx.  The  treatment  is  that  of 
superinvolution  of  the  uterus  {q.  v.) 

Cancer  of  the  Cervix  (Cervecal  Carcinoma) 

Frequency.- — -The  uterus  is  the  commonest  site  of  cancer  in 
the  human  body.  Cancer  is  four  times  as  frequent  in  the  cer- 
\dx  as  in  the  body  of  the  uterus. 

Age  of  Occurrence. — ]\Iost  commonly  between  the  ages  of 
forty  and  fifty.  About  one-third  of  the  cases  are  between 
thirty  and  forty.  It  is  occasionally  seen  prior  to  thirty  and 
after  sixty,  but  these  are  rare.  It  has  been  reported  at  eight- 
een, and  as  late  as  eighty-two  years  of  age. 

Cause. — Nearly  aU  patients  with  cancer  of  the  cervix  have 
had  children  (98  per  cent.)  and  the  vast  majority  have  had 
several — five  being  the  average.  Therefore  inflammation 
or  traumatic  lesions  of  the  cer\dx,  due  to  childbirth,  are  very 
constant  etiologic  factors.  Neglected  laceration  of  the  cervix, 
mth  eversion  and  particularly  erosion,  is  the  most  frequent 
cause.  Cancer  in  a  nullipara  may  start  in  an  erosion,  or  in 
some  injury  to  the  cerv^ix,  as  after  forcible  dilatation.  The 
actual  exciting  cause  in  not  known.  Heredity  does  not  play 
an  important  part.  Many  theories  have  been  advanced  but 
none  proven. 


ABNORMALITIES  OF  THE  CERVIX  61 

Classification. — Cancer  of  the  cervix  is  classified  under 
two  heads:  the  clinical  and  the  pathological. 

The  clinical  varieties  are:  (i)  Cauliflower — the  only  squa- 
mous-cell  variety — and  much  the  commonest  type.  It  origi- 
nates from  the  squamous  epithelium  of  the  vaginal  portion; 
(2)  ulcerative — 'Originating  in  the  cylindrical  epithelium  of  the 
cervical    canal,    and    is    adenocarcinoma;     (3)  interstitial    or 


Ca 


Vagina 


Ulceration 


Pig.  29. — a,  Cauliflower  squamous-celled  cancer  of  the  cervix;  b,  ulcera- 
tive adenocarcinoma  of  the  cervical  canal.      {After  Graves.) 

indurating — originating  in  the  deeper  portions  of  the  cervical 
glands,  and  only  secondarily  ulcerative — in  its  later  stages. 
Of  the  clinical  varieties  the  cauliflower  bleeds  the  most,  the 
interstitial  the  least;  and  the  interstitial  is  the  most  insidious 
and  most  likely  to  be  overlooked. 

The  pathological  varieties  are:  (i)  Squamous  epithelioma, 
with  epithelial  pearls  (the  cauliflower  type);  (2)  adeno- 
carcinoma— with  hyperplasia  of  the  lining  epithelium  of  the 
glands,  perforation  of  the  basement  membrane  and  infiltration 


ABNORMALITIES  OF  THE  CERVIX,  EXCLUDING  TEARS 


of  the  myometrium  (the  ulcerative  and  interstitial  types); 
(3)  malignant  adenoma — malignant  hyperplasia  of  the  glands 
themselves  without  hyperplasia  of  the  lining  (more  rarely 
in  the  ulcerative  and  interstitial  t5Apes);  (4)  malignant 
endothelioma— Si  rare  growth  from  the  endothelium  of  the 
lymph  spaces  and  vessels. 


Ca-t\cer,,\ 


\J\CLercxCvoxv 


^Crater 


Infiltration 
'  of  Vagin/z. 


Fig.  30.  Fig.  31. 

Fig.  30. — -Inverting  cancer  of  the  cervix.  In  this  case  the  growth  is 
invading  the  walls  of  the  cervix  with  little  tendency  to  extend  outward 
into  the  vagina.  In  this  type  there  is  an  earlier  invasion  of  the  para- 
metrium. It  can  be  seen  from  the  drawing  that  the  disease  might  escape 
detection  by  the  examining  finger.  This  form  of  the  disease  is  especially 
treacherous,  as  it  is  liable  to  be  overlooked.      {After  Graves.) 

Pig.  31. — Extensive  crater  formed  by  carcinoma  of  the  cervix,  with  in- 
filtration of  the  vagina.      (After  Graves.) 

Direction  of  Metastasis. — ^Lymphatic  metastasis  takes  place 
into  the  deep  sacral,  lumbar  and  finally  the  renal  glands. 
Cancer  of  the  cervix  also  spreads  by  direct  continuity  to  the 
bladder,  rectum  and  vaginal  vaults.  It  almost  never  gives 
metastasis  to  the  groin,  and  rarely  to  distant  organs.  Vesico- 
vaginal and  recto-vaginal  fistulse  are  common  complications 
of  the  later  stages. 


ABNORMALITIES  Ol'  THE  CERVIX  83 

How  Cancer  Kills.^ — (i)  Cachexia,  secondary  anemia  and 
exhaustion;  (2)  hemorrhage;  (3)  intestinal  obstruction;  (4) 
septic  pyelitis;  (5)  general  septicemia;  (6)  rarely  from  distant 
metastases;  (7)  pulmonary  embolism  from  the  accompany- 
ing thrombophlebitis.  The  usual  duration  from  the  appear- 
ance of  the  first  symptoms  is  one  to  three  years. 

Clinical  History  and  Symptoms. — There  are  three  cardinal 
symptoms  of  cancer  of  the  cervix: 

Bleeding. — This  is  irregular  from  the  start,  due  to  capillary 
erosion,  and  occurs  either  near  the  time  of  the  menopause  or 
after  the  menopause  has  been  established.  It  may  be  a 
blood-stained  watery  discharge,  but  is  usually  frank  bleeding. 

Irregular  bleeding  in  any  patient  past  .35  is  a  symptom  that 
demands  immediate  and  thorough  investigation.  Ignorance 
or  neglect  of  this  dictum  is  why  over  60  per  cent,  of  cases 
first  present  themselves  for  treatment  after  the  cancer  is 
inoperable. 

2.  Fold  Discharge. — This  occurs  relatively  early  in  the  cauli- 
flower growth,  later  in  the  ulcerative  and  latest  in  the  inter- 
stitial. It  is  due  to  necrosis  and  sloughing.  Periodic  gushes 
of  pus  are  due  to  obstruction  of  the  cervix  and  pyometra. 
The  discharge  is  very  foul,  and  is  most  profuse  in  cauliflower 
growths.  In  the  others,  it  is  likely  to  be  watery  for  a  con- 
siderable time. 

3.  Pain,  is  a  late  symptom,  and  of  no  value  in  an  early 
diagnosis.  The  cervix  is  relatively  insensitive,  and  pain 
appears  only  when  the  growth  has  involved  the  vaginal  vaults 
or  the  sacral  plexus.  The  presence  of  pain,  with  rare  excep- 
tions, means  that  the  case  is  inoperable. 

Cachexia  occurs  very  late,  and  never  in  cases  that  are  oper- 
able. It  is  extreme,  however,  when  it  does  occur.  Fever  is 
common,  and  due  to  infection  and  not  the  ulcerated  mass  per  se. 

Diagnosis  is  comparatively  easy.  All  cases  are  operable  in 
the  early  stage.  Any  patient  who  complains  of  irregular  bleed- 
ing should  be  examined,  in  the  dorsal  position,  and  the  cervix 
inspected  through  a  bivalve  speculum.     A  suspicious  erosion 


84  ABNORMALITIES  OF  THE  CERVIX,  EXCLUDING  TEARS 

or  induration,  particularly  if  it  bleeds  to  a  slight  touch,  should 
have  a  piece  removed  by  tenaculum  and  scissors,  for  micro- 
scopical examination.  This  is  painless  and  the  resulting  bleed- 
ing slight  and  easily  controlled  by  a  tampon.  If  the  source  of 
the  bleeding  is  not  in  the  cervix  an  exploratory  dilatation  and 
curettage  of  the  uterine  cavity  must  be  done,  and  the  scrap- 


PiG.   32. — Jung-Hobel    freezing    microtome;    ether    spray. 

ings  examined  microscopically.  With  these  simple  precau- 
tions, most  if  not  all  cases  can  be  recognized  early  enough  to 
give  operative  removal  a  brilliant  chance  of  success.  In  the 
stage  where  the  patient  usually  presents  herself  for  treatment, 
recognition  is  easy.  The  cauliflower  growth  fills  the  vaginal 
vault  with  a  friable,  bleeding,  sloughing  mass,  surrounded  by 
an  indurated  ring  of  cervix.  The  ulcerative  growth  (adeno- 
carcinoma) shows  as  a  sloughing  crater  in  the  cervix,  bleeding 


ABNORMALITIES  OF  THE  CERVIX  85 

easily  to  the  touch.  The  interstitial,  prior  to  the  stage  of  ulcera- 
tion, shows  a  stony,  hard,  hypertrophied  cervix,  usually  fixed 
and  immovable,  and  requires  for  diagnosis  curettage  of  the 
cervical  canal  or  removal  of  a  piece  of  the  cervix  for  micro- 
scopical diagnosis.  In  any  case  where  doubt  exists,  the  micro- 
scope will  infallibly  decide. 

Simple  erosion  of  the  cervix  bleeds  easily,  but  is  not  indurated, 
is  not  friable,  causes  no  destruction  of  tissue,  has  no  foul 
discharge,  and  the  microscope  will  show  benign  growth. 

A  normal  polyp  is  not  ulcerated  and  does  not  infiltrate.  A 
sloughing  polyp  has  no  infiltration  at  its  base,  no  deep  ulcera- 
tion, no  infiltration  of  surrounding  tissue,  but  is  friable  and 
can  be  broken  up  with  the  fingers. 

Syphilis  yields  promptly  to  specific  treatment. 

Sarcoma  is  only  distinguishable  by  microscopic  examination. 

Tuberculosis  shows  a  punched  out  ulcer  with  undermined 
edges,  pale  granulation,  little  bleeding,  and  the  microscope  and 
inoculation  experiments  will  settle  all  doubts. 

In  cases  where  time  is  an  object,  the  freezing  microtome  will 
give  a  diagnosis  in  a  few  minutes.  In  all  cases,  it  is  wiser  to 
take,  if  possible,  the  slower  but  more  accurate  paraffin  or 
cello^din  method. 

A  case  is  operable:  i.e.,  suitable  for  hysterectomy, 
(i)  When  the  uterus  is  movable;  (2)  when  there  is  no  invasion 
of  the  broad  ligaments;  (3)  when  there  is  no  involvement 
of  the  vaginal  vaults,  bladder  or  rectum.  Conversely  when 
the  uterus  is  fixed,  the  broad  ligaments  infiltrated,  the  vaginal 
vaults  indurated  and  extension  to  the  bladder  and  rectum 
walls,  any  attempt  at  radical  operation  is  hopeless. 

The  interstitial  variety  reaches  the  inoperable  stage  earliest, 
and  only  about  one-third  of  the  cases  presenting  themselves 
for  treatment  permit  of  radical  operation.  The  presence  of 
enlarged  lymph-glands  does  not  mean  that  these  glands  are 
cancerous,  and  if  they  are,  it  does  not  mean  the  case  is 
hopeless,    though    the    prognosis    is    unquestionably    worse. 


86  ABNORMALITIES  OF  THE  CERVIX,  EXCLUDING  TEARS 

These  glands  can  be  extirpated  with  the  uterus,  and  perma- 
nent cure  result. 

Methods  of  radical  operation  are  of  three  types,  (i) 
Abdominal  pan-hysterectomy — preferably  by  the  technic  of 
Wertheim.  (2)  Vaginal  panhysterectomy.  (3)  Combined 
vaginal  and  abdominal  panhysterectomy,  where  the  uterus  is 
freed  from  its  lower  attachments  through  the  vagina,  and  is 
removed  through  the  abdomen. 

Abdominal  panhysterectomy  is  preferable  as  a  routine  pro- 
cedure. 

Vaginal  hysterectomy  has  certain  advantages:  (i)  Rapidity 
of  operation;  (2)  absence  of  shock;  (3)  in  fat  women;  (4)  a 
lower  primary  mortality.  Its  disadvantages  are:  (i)  Lack 
of  room;  (2)  danger  of  clamping  of  ureters;  (3)  danger  of 
injury  to  bladder  and  rectum  in  advanced  cases;  (4)  difficulty 
in  dealing  with  adhesions;  (5)  a  lower  percentage  of  five-year 
cures;  (6)  danger  of  secondary  hemorrhage. 

The  ideal  case  for  vaginal  hysterectomy  is  the  patient  who 
is  very  fat,  who  could  not  stand  the  Trendelenburg  position 
demanded  by  the  abdominal  route;  who  has  a  movable 
uterus,  with  no  direct  metastases,  with  relaxed  pelvic  floor. 
All  advanced  cases  are  best  done  by  the  abdominal  route. 

Technic.  (i)  Wertheim  Abdominal  Panhysterectomy. — (i) 
The  patient  is  prepared  as  for  any  pelvic  operation  and  anes- 
thetized. 

2.  She  is  arranged  in  the  dorsal  position  and  the  vagina 
cleansed. 

3.  Any  sloughing  mass  is  removed,  and  its  base  thoroughly 
seared  with  the  cautery. 

4.  The  vagina  is  painted  with  5  per  cent,  tincture  of  iodin 
and  packed  with  sterile  gauze. 

5.  The  patient  is  placed  in  the  extreme  Trendelenburg 
position  and  the  abdomen  opened  in  the  middle  line,  the  lower 
end  of  the  incision  being  on  the  symphysis;  a  seh-retaining 
abdominal  retractor  is  put  in  place  and  all  intestines  packed  out 
of  the  pelvis. 


ABNORMALITIES  OF  THE  CERVIX 


87 


6.  The  uterus  is  caught  by  a  Somers  clamp  and  held  forward. 

7.  The  ovarian  arteries  and  round  ligaments  are  ligated  on 
both  sides,  and  a  clamp  placed  above  the  ligatures  to  control 
reflex  bleeding. 

8.  The  broad  ligaments  and  peritoneum  are  split  anteriorly 
from  one  side  of  the  pelvis  to  the  other,  above  the  attachment 
of  the  bladder. 

9.  The  bladder  is  freed  anteriorly,  and  both  broad  ligaments 
dissected  down  until  the  ureters  are  exposed. 


Pig.   33. — Diagram  illustrating  the  tissue  to  be  removed  in  the  radical 
operation  for  cancer  of  the  cervix.      (After  Kelly.) 


ID.  The  uterine  arteries  are  caught  outside  the  ureters,  cut 
and  hgated. 

11.  The  peritoneum  is  separated  posteriorly  and  both  utero- 
sacral  ligaments  caught  and  tied. 

12.  The  uterus  is  pulled  strongly  upward,  and  a  clamp  placed 
on  each  side  so  as  to  include  the  angle  of  the  vagina. 

13.  The  vagina  is  cut  across  and  the  uterus  removed. 

14.  The  vagina  is  immediately  closed,  with  number  3  chromic 
catgut. 

15.  Two  ligatures  are  placed  under  the  clamps  securing  the 
angles  of  the  vaginal  wound  and  tied  outside  the  clamps.     This 


88  ABNORMALITIES  OF  THE  CERVIX,  EXCLUDING  TEARS 

secures,  with  one  stitch,  the  troublesome  uterovaginal  venous 
plexus. 

1 6.  Any  obvious  glands  are  removed.  Extended  search  is 
not    necessary. 

17.  The  peritoneum  is  closed  over  the  vaginal  stump,  with 
number  3  chromic  catgut. 

18.  The  packs  are  removed  and  the  abdomen  closed. 

19.  The  vaginal  packing  is  removed  at  the  completion  of 
the  operation. 

Technic  of  Vaginal  Hysterectomy. — i.  The  patient  is  pre- 
pared as  for  any  pelvic  operation  and  anesthetized. 

2.  The  cervix  is  sterilized  with  the  cautery,  and  pulled 
down  by  a  double  tenaculum. 

3.  The  cervix  is  freed  from  its  vaginal  attachments  by  a 
circular  incision. 

4.  The  bladder  is  pushed  up  anteriorly,  with  gauze,  a  retrac- 
tor placed  under  it  for  protection,  and  the  anterior  pouch  of 
the  peritoneum  caught  and  opened. 

5.  The  uterus  is  caught  with  a  volsellum  and  anteverted 
through  this  peritoneal  opening. 

6.  The  broad  ligaments  are  caught  in  clamps,  and  cut 
through  near  the  uterus.  Three  clamps  to  each  side  are 
needed. 

7.  A  better,  though  more  difficult  plan,  is  to  ligate  the  broad 
ligaments,  with  three  ligatures,  cutting  free  each  section  as  it  is 
tied,  and  holding  the  stumps  with  a  hemostat. 

8.  When  the  broad  ligaments  are  tied  or  clamped  and 
cut,  the  peritoneum  is  opened  posteriorly,  and  the  uterus 
reinoved. 

9.  If  ligatures  have  been  used,  the  stumps  of  the  broad  liga- 
ments are  sewed  together,  the  peritoneum  and  vaginal  walls 
closed  over  them  with  number  3  chromic  catgut.  If  clamps 
were  used,  the  pelvis  and  vagina  around  the  clamps  is  packed 
with  gauze,  and  the  handles  of  the  clamps  so  supported  by  a 
suspensory  bandage  that  the  blades  are  not  dragged  upon. 
Clamps    are    cautiously   removed,    after    seventy-two    hours. 


ABNORMALITIES  OF  THE  CERVIX  SQ 

Technic  of  Combined  Hysterectomy. — i .  This  is  the  same  as  the 
vaginal  operation  until  the  peritoneum  is  opened  anteriorly. 
2.  From  this  point  it  is  the  same  as  the  Wertheim. 

Prognosis  after  operation  depends  greatly  upon  how  advanced 
the  disease  was  when  the  operation  was  done.  The  most 
optimistic  reports  give  30  per  cent,  as  free  from  recurrence  for 
five  years.  Ten  per  cent,  would  be  a  more  accurate  average. 
The  primary  mortality  is  from  6  per  cent,  to  10  per  cent.,  the 
chief  causes  of  death  being  peritonitis  and  secondary 
hemorrhage. 

Palliative  Treatment  of  Inoperable  Cases. — This  is  applicable 
to  cases  so  far  advanced  that  complete  removal  is  not  possible. 

Methods. — ^I.  Ctiret,  Heat  and  Chemical  Cautery. 


Pig.  34. — Paquelin's  cautery.      Note  that  the  benzene  is  contained  in  the 
handle  of  the  apparatus.      (Ashton.) 

Technic- — i.  The  patient  is  anesthetized,  and  placed  in  the 
dorsal  position. 

2.  The  crater  of  the  cervix  is  exposed  by  a  cylindrical  wooden 
Ferguson  or  water-cooled  cylindrical  speculum.  The  ordinary 
metal  ones  get  too  hot  during  the  cauterization. 

3.  The  sloughing  mass  of  cancer  is  curetted  away  by  a 
curet  with  saw-tooth  edges. 

4.  As  soon  as  reasonably  firm  tissue  is  reached,  the  crater 
is  thoroughly  cooked  with  the  electric  dome  or  Paquelin  button 


90  ABNORMALITIES  OF  THE  CERVIX,  EXCLUDING  TEARS 

cautery.     The  electric  is  much  the  better,  and  the  point  in 

either  one  should  be  a  dull  cherry  red,  to  minimize  bleeding. 

5.  The  cavity  is  then  packed  with  a  tampon  soaked  in  50 

per  cent,  zinc  chlorid  solution,   or   equal   parts  of  adrenalin 


Fig.  35. — Transformer  for  electrocautery.  This  is  a  rheostat  and 
motor,  as  required  for  the  direct  current.  An  alternating  current  requires 
the  rheostat  only,  which  is  a  much  less  expensive  apparatus.  The  cable 
shown  can  be  boiled,  but  the  insulation  rots  quickly.  It  is  equally  good 
to  cover  the  cable  with  sterile  towel.      {B.  C.  Hirst.) 

i-iooo    and    40    per   cent,  formaldehyd  solution   (the  stock 
solution) . 

6.  The  wet  tampon  is  held  in  place  by  other  tampons  thickly 
smeared  with  an  ointment  of  30  per  cent,  sodium  bicarbonate 
in  vaselin,  to  prevent  vaginal  eschars. 


Pig.  36. — Electrocautery  point.     The  dome-shaped  spiral  is  kept  at  a 
constant  dull  red  heat.      {B.  C.  Hirst.) 

7.  The  tampons  are  taken  out  in  eight  days,  the  patient 
kept  in  bed  for  ten.  H3^podermics  of  morphin  are  used,  in 
ascending  doses,  to  control  pain. 


yVBNORMALlTlES  OF  TTIE  CERVIX  QI 

II.  The  Percy  low-heat  method  is  based  upon  the  theory  that 
cancer  cells  cannot  withstand  a  temperature  of  45°C.  for  ten 
minutes,  while  the  normal  cell  will  withstand  6o°C.  The 
cervix  is  exposed  through  a  water-cooled  cylindrical  speculum, 
the  electric  cautery  point  is  pushed  into  the  mass  and  the 
current  turned  on.  An  assistant,  through  a  small  abdominal 
incision,  holds  the  fundus  uteri  in  his  hand,  and  when  the 
uterine  body  becomes  uncomfortably  hot  to  his  gloved  hand, 
the  direction  of  the  cautery  point  is  changed.  Frequently, 
preliminary  ligation  of  the  internal  iliacs  is  done,  when  hemor- 
rhage is  feared.  By  this  method  the  gross  malignant  mass  is 
often  removed  at  one  sitting,  though  usually  several  are  re- 
quired. It  is  not  free  from  danger,  hemorrhage,  fistulas 
and  deep-seated  abscess  being  frequent  complications. 

III.  Byrne  Method — the  oldest  of  the  cautery  methods.  By 
means  of  the  cautery  knife  and  button  cautery  the  uterus 
is  slowly  burned  out,  so  that  a  mere  shell  is  left.  The  degree  of 
heat  is  a  dull  cherry  red,  and  the  knife  or  button  are  always 
placed  in  contact  with  the  tissue  to  be  cut,  before  the  current 
is  turned  on.  This  is  to  minimize  bleeding.  The  results  have 
been   excellent. 

IV.  X-ray  in  the  treatment  of  cancer  of  the  cervix  has 
been  a  disappointment. 

V.  Radium  is  of  great  value,  particularly  in  the  recur- 
rences after  operation.  It  is  applied  for  three  or  four  hours  to 
five  days  at  a  time,  being  either  implanted  in  the  cervix,  or 
held  in  place  by  a  tampon.  One  hundred  milligrams  are 
used  and  two  or  three  weeks  rest  between  treatments  is  given. 
The  gamma  rays  penetrate  three  to  four  centimeters. 

The  therapeutic  value  of  radium  depends  on:  (i)  The  amount 
used;  (2)  the  nature  of  the  filter  (brass  being  the  best);  (3) 
the  method  of  application;  (4)  the  length  of  exposure;  (5)  the 
frequency  of  treatment. 

The  results  are  often  brilliant,  sometimes  utterly  disappoint- 
ing, but  occasionally  radium  will  transform  an  inoperable  into 
an  operable  case.     No  operation  should  be  undertaken  until 


92  ABNORMALITIES  OF  THE  CERVIX,  EXCLUDING  TEARS 

three  weeks  from  the  last  radium  treatment,  because  of  the 
danger  of  sepsis. 

VI.  Mesothorium  is  used  as  radium,  but  the  supply  is  very 
limited  and  it  is  no  more  effectual  than  radium. 

Length  of  life  after  palliative  treatment  varies  with  the  extent 
of  the  disease  when  seen.  After  curetment  and  cauteriza- 
tion, the  patient  usually  markedly  improves,  the  discharge 
and  bleeding  cease,  and  for  a  time  she  will  even  gain  in 
weight.  Life  is  prolonged  for  eighteen  months  to  five  years, 
and,  rarely,  repeated  cauterization  has  resulted  in  a  sympto- 
matic cure. 

After-treatment  of  palliated  cases  consists  in:  (i)  Frequent 
vaginal  douches  (two  daily)  of  lysol  solution  one  dram  to 
two  pints  or  formalin  i  per  cent.;  (2)  full  diet;  (3)  laxatives 
to  secure  daily  movements;  (4)  local  applications  of  acetone 
to  the  cervical  crater,  when  the  bleeding  and  discharge  return; 
(5)  morphin  in  sufficient  doses  to  control  the  pain.  This  will 
be  needed  first  at  night,  and  later  at  frequent  intervals,  night 
and  day;  (6)  the  patient  had  better  not  be  told  she  has  cancer, 
on  account  of  the  mental  depression. 

Recurrence  after  removal  of  the  uterus  takes  place  any  time 
from  a  few  weeks  to  five  or  more  years.  The  vast  majority 
occur  in  the  first  six  months,  and  after  five  years  recurrence 
is  very  rare.  The  first  symptom  is  slight  irregular  bleeding. 
Vaginal  examination  shows  a  hard  nodule  in  the  scar  in  the 
vaginal  vault,  with  a  small  granulating  area,  and  bleeding 
easily  to  the  touch.  The  extent  of  involvement  is  best  made 
out  by  rectal  examination.  Pain  is  of  a  burning  character 
and  is  usually  very  severe. 

Treatment  is  radium,  either  with  or  preferably  without  a 
preliminary  superficial  cauterization.  No  other  treatment 
offers  any  hope,  but  radium  will  often  cause  the  prompt 
disappearance  of  surprisingly  large  recurrences.  The  patient 
must  be  closely  watched,  however,  as  re-recurrence  is  very 
possible,  and  is  treated  in  the  same  way. 


abnormalities  op  the  cervix  93 

Cervicitis  and  Endocervicitis  (Chronic  Cervical  Catarrh) 

Cervicitis  and  endocervicitis,  except  where  caused  by  lacera- 
tion in  childbirth,  are  due  to  specific  or  non-specific  infection. 

Pathology.- — The  glands  are  dilated,  the  lining  epithelium 
in  places  absent.  The  stroma  is  edematous  and  infiltrated 
with  round  cells. 

Symptoms.- — ^Leukorrheal  discharge,  of  thick,  stringy, 
mucopus,  profuse  enough  to  require  a  napkin  for  protection, 
is  the  only  symptom.  Through  a  bivalve  speculum,  erosion 
of  the  vaginal  portion  of  the  cervix,  especially  on  the  posterior 
lip,  and  the  discharge  issuing  from  the  canal  can  be  seen. 

Treatment- — (i)  Repeated  vaginal  douches  (two  a  day.)  of 
zinc  sulphate  and  alum;  (2)  tampons  of  boroglycerid  25 
per  cent,  or  ichthyol  50  per  cent. ;  (3)  local  application,  through 
a  bivalve  speculum,  of  7  per  cent,  tincture  of  iodin  or,  better, 
nitrate  of  silver  8  per  cent.  (40  grains  to  the  ounce) ;  (4)  instilla- 
tion, every  other  day,  into  the  cervical  canal  of  50  per  cent, 
ichthyol,  50  per  cent,  argyrol  or  5  per  cent,  silvol  paste.  In- 
stillations are  best  in  the  form  of  a  slowly  melting  paste,  rather 
than  solutions,  as  the  paste  is  retained  long  enough  to  penetrate 
into  the  glands.  The  technic  is  described  in  Chapter  II;  (5) 
in  obstinate  cases,  amputation  of  the  cervix,  or  Schroder's 
operation  of  removal  of  the  cervical  mucosa,  by  wedge-shaped 
excision  of  each  lip.  The  condition  is  often  very  stubborn,  and 
will  persist  for  years. 

Ectropion  of  the  Cervix  (Eversion) 

This  is  the  result  of  bilateral  laceration,  the  lips  of  the  cervix 
diverging  like  a  split  stalk  of  celery.  The  lips  are  asymmetrical, 
the  anterior  being  usually  the  longer.  The  deep  red  mucosa  of 
the  cervical  canal  is  exposed.  If  the  tear  is  stellate,  there  is 
often  considerable  hypertrophy  of  the  cervix. 

Symptoms.- — ^Leukorrheal  discharge.  The  diagnosis  is  made 
through  a  bivalve  speculum. 


94 


.ABNORMALITIES  OF  THE  CERVIX,  EXCLUDING  TEARS 


Treatment.^ — Repair  of  the  injury,  or,  of  the  cervix  is  hyper- 
trophied,  amputation  of  the  cervix.  For  details  of  technic 
see  Chapter  XII. 


Erosion  of  the  Cervix- 

This  is  a  prolapse  of  the  deep  red  columnar  epithelium  of 
the  vaginal  portion  of  the  squamous  epithelium  of  the  vaginal 
portion  of  the  cervix..  It  is  not  ulceration,  though  it  has 
that  appearance.  It  is  most 
often  caused  by  laceration  of 
the  cervix,  though  it  may  be 
the  result  of  any  irritation. 
It  is  not  infrequently  seen  in 
virgins,  supposedjy  due  to  mal- 
position of  the  cervix  with  re- 
troflexion or  anteflexion  of  the 
uterus,  so   that  there  is  undue 


Pig.  37. — Bilateral  laceration  Fig.   38. — Erosion  and  aversion  of 

of  the  cervix,  with  marked  ever-  the    cervix,    secondary    to    bilateral 

sion,   as   seen  through  a  bivalve  laceration.      {After  Crossen.) 
speculum.      {After  B.  C.  Hirst.) 

friction  between  the  cervix  and  the  vaginal  walls.  Erosion 
is  common  in  gonorrhea  and  in  non-specific  infection  of  the 
cervix. 

Symptoms. — ^Leukorrheal  '  discharge,  often  blood-stained, 
because  the  cylindrical  epithelium  bleeds  at  the  slightest  touch. 
The  diagnosis  is  made  through  a  bivalve  speculum,  which  shows 
plainly  the  red,  angry  area  of  hyperplastic  cervical  mucosa. 


ABNORMALITIES  OF  THE  CERVIX  95 

Digital  examination  alone  is  unsatisfactory;  the  erosion  is 
not.  easily  felt,  and  its  extent  cannot  be  ascertained. 

Treatment. — (i)  If  due  to  laceration,  repair  or  amputation 
of  the  cervix,  the  latter  if  it  is  hypertrophied,  is  required. 
No  form  of  local  application  will  cure  permanently  an  erosion 
due  to  laceration;  (2)  if  due  to  non-gonorrheal  endometritis, 
dilatation  and  curettage  of  the  uterus.  In  gonorrhea,  this 
is  to  be  avoided,  as  it  will  very  probably  be  followed  by  pus 
tubes;  (3)  nitrate  of  silver  (8  per  cent.;  40  grains  to  the 
ounce)  applied  through  a  bivalve  speculum  three  times  a 
week;  (4)  tampons  of  boroglycerid  25  per  cent,  or  ichthyol 
50  per  cent.' — three  times  weekly;  (5)  daily  vaginal  douche  of 
zinc  sulphate  and  alum  solution  (see  Chapter  II);  (6)  in- 
stillations into  the  cervix  of  5  per  cent,  silvol  paste,  three 
times  weekly;  (7)  in  the  erosion  of  virgins,  instillation  or 
amputation  of  the  cervix.  Any  erosion  is  a  possible  site  of 
cancer,  hence  intractable  ones  should  be  excised  and  examined 
microscopically. 

Hypertrophy  of  the  Cervix 

This  is  nearly  always  the  result  of  laceration  and  consequent 
hyperplasia  of  the  cervical  connective- tissue  stroma.  The 
complicated  racemose  glands  easily  become  obstructed  and 
cystic,  and  often  show  on  the  vaginal  portion,  as  small  pearly 
cysts,  the  Nabothian  follicles. 

Hypertrophic  elongation  of  the  cervix  is  a  consequence  of 
prolapse  of  the  uterus,  due  to  the  pull  of  the  vaginal  walls. 

Diagnosis  is  made  by  palpation,  inspection  through  a  bivalve 
speculum,  or  by  simple  inspection,  if  the  case  is  one  of  prolapse. 

Treatment  is  amputation  of  the  cervix. 

Cervical  Myoma 

Cervical  myoma  is  primarily  very  rare.  Most  cervical 
myomata  are  polypoid,  and  have  originate'd  in  the  lower 
uterine  segment  and  grow  downward.  True  cervical  myoma 
grows  as  any  other  fibroid,  causes  pressure  symptoms  on  the 


g6  7VBNORMALITIES  OF  THE  CERVIX,  EXCLUDING  TEARS 

bladder  and  rectum  comparatively  early.  The  diagnosis  is 
made  by  bi-manual  examination.  Because  of  their  bulk,  a 
satisfactory  specular  examination  is  difficult  or  impossible. 
The  treatment  is  removal  through  the  vagina,  usually  by 
morcellation,  and  is  attended  with  considerable  risk  of  injury 
to  the  bladder  and  rectum. 

Nabothian  Follicles 

When  as  a  result  of  chronic  irritation,  the  cervical  glands 
are  obstructed  and  cystic,  they  often  show  upon  the  vaginal 
portion  of  both  hps  as  small  pearly  cysts.  These  are  the 
Nabothian  follicles,  but  the  glands  from  which  they  come  are 
noi  Nabothian  glands. 

The  follicles  contain  cervical  mucus,  as  a  rule  clear,  but 
sometimes  purulent  from  secondary  infection.  They  may  be 
felt  by  digital  examination,  but  a  bivalve  speculum  shows  them 
plainly. 

If  punctured,  they  usually  refill,  and  the  only  satisfactory 
cure  is  trachelorrhaphy  or  amputation  of  the  cervix. 

Cervical  Polyps 

Cervical  polyps  are  very  common.  They  are  seen  most 
frequently  after  forty  years  of  age,  though  no  age  is  exempt. 
They  are  a  very  common  cause  of  bleeding  after  the  menopause. 

Kinds.- — I.  Mucous  Polyps — the  commonest — represents  a 
hypertrophy  of  the  endocervical  mucosa.  They  are  often 
multiple,  rarely  of  large  size,  are  bright  red  or  purplish  in 
color,  grow  from  any  portion  of  the  cervical  canal  and  are  most 
often  pedunculated. 

2.  Fibroid  or  fibro-adenomaious  polyps  are  larger,  may 
attain  the  size  of  a  child's  head,  and  either  project  from  the 
cervix  or  are  contained  in  a  cavity  representing  the  dilated 
cervical  canal,  like  a  ball  in  a  socket.  They  are  usually  single. 
They  are  bright  red  in  color,  and  very  firm  to  the  touch — a 
marked  contrast  to  the  soft  mushy  mucous  pol}^^.  They  might 
easily  be  mistaken  for  the  ovum  in  inevitable  abortion,  retained 
within  the  cervical  canal,  but  are  much  more  solid  in  feel. 


ABNORMALITIES  OF  THE  CERVIX 


97 


Attachments. — (i)  Pedtmculated- — much  the  commonest,  the 
pedicle  being  relatively  slender,  especially  in  the  mucous  type. 
(2)  Sessile,  where  the  attachment  is  broad  and  firm. 

Symptoms. — (i)  Bleeding — irregular  and  often  very  profuse. 
(2)  Leukorrhea — varying  from  the  thin  serous  discharge  of  the 
fibroid  polyps  to  the  profuse  mucopurulent  type  seen  in 
infected  mucous  polyps.  (3)  Pain  is  not  present,  except  in 
globular  fibroid  polyps  in  the  cervical  canal,  when  it  is  expulsive, 
like  that  of  miscarriage,  but  less  intense. 


Fig. 


39- 


-Fibro-adenomatous  polyps,  hanging  from  the  cervical  canal. 
(After  B.  C.  Hirst.) 


Diagnosis.- — (i)  Digital  examination.  The  mucous  polyp  is 
soft,  the  fibroid  hard  and  firm.  (2)  Bivalve  speculum  shows 
the  growth  protruding  through  the  os  or  visible  in  the  dilated 
canal. 

Before  any  attempt  is  made  to  remove  a  large  fibroid  polyp, 
inversion  of  the  uterus  must  be  excluded. 

Degenerations.- — (i)lnfection,  (2)  cystic,  (3)  gangrene,  (4) 
malignant  (carcinoma  in  the  mucous,  sarcoma  in  the  fibroid. 

Treatment.- — No  polyp  is  innocent,  and  all  must  be  removed. 
The  method  of  removal  depends  upon  the  attachment.  Mucous 
polyps  are  pedunculated,  fibroid  polyps  may  be  grasped  with 
a  forceps  and  cut  off,  snared  off  or  best  twisted  off.  Bleeding 
is  not  to  be  feared.  Sessile  polyps  require  splitting  of  the 
cervix  anteriorly,  incision  of  the  capsule  at  the  base  of  the 
7 


gS  .ABNORMALITIES  OF  THE  CERVIX,  EXCLUDING  TEARS 

growth,  when  the  pol>^  may  be  seized  with  a  volsellum  and 
enucleated  with  the  lingers .  No  ligatures  are  required,  as 
the  blood  supply  is  poor.  A  very  broad  base  will  require  two 
or  three  transverse  catgut  sutures  to  close  it,  and  the  incision 
in  the  anterior  lip  of  the  cervix  is  closed  after  the  tumor  is 
removed. 

In  every  case,  the  removal  of  the  polyp  should  be  followed 
by  a  dilatation  and  curettage,  and  both  the  polyp  and  scrap- 
ings should  always  be  examined  microscopically  for  malig- 
nancy. A  polyp  of  any  kind  is  best  removed  under  anesthesia 
and  in  proper  hospital  surroundings  and  not  as  an  ofi&ce  pro- 
cedure. Dangerous  infection  may  follow  neglect  of  this 
precaution. 

Sarcoma  of  the  Cervix 

Sarcoma  is  exceedingly  rare,  except  as  sarcomatous  degenera- 
tion of  a  fibroid  pol}^.  Primary  sarcoma  occurs  as  a  hyda- 
tidiform  growth,  of  a  purple  color,  extended  from  the  cervix. 
The  symptoms  and  treatment  are  those  of  cancer  of  the  cervix. 
Radium  is  said  to  be  more  active  and  efficient  in  sarcoma 
than  in  cancer,  but  this  is  very  doubtful. 

The  prognosis  is  bad.     All  the  reported  cases  have  died. 

Tuberculosis  of  the  Cervix 

Tuberculosis  is  rare,  much  less  common  than  in  the  body 
of  the  uterus.  The  infection  is  primary  and  appears  as  an 
irregular  punched  out  ulcer,  with  ragged  undermined  edge  and 
pale  granulations.  The  accurate  diagnosis  is  made  by  excision 
and  microscopic  examination. 

Treatment.- — If  there  is  widespread  tuberculosis  elsewhere, 
palliative  treatment  (local  cauterization)  alone  is  required. 
If  there  is  no  evidence  of  general  tuberculosis,  amputation 
of  the  cervix,  or  panhysterectomy. 

Ulceration  of  the  Cervix 

Ulceration  of  the  cervix  is  a  much  abused  term.  Usually 
it  is  synonymous  with  erosion,  which  is  not  a  true  ulcer.     True 


ABNORMALITIES  OF  THE  CERVIX  99 

ulceration,  with  actual  loss  of  substance,  is  seen  in  prolapse 
of  the  uterus,  chancre,  chancroids,  cancer  and  tuberculosis. 

The  ulcers  of  prolapse  arg  treated  by  reposition  of  the  uterus, 
rest  in  bed,  and  boroglycerid  tampons. 

Chancre  heals  promptly  under  neosalvarsan. 

Chancroids  require  cauterization  with  the  cautery,  carbolic 
acid  or  fuming  nitric  acid. 

Cancer  and  tuberculosis  both  require  panhysterectomy. 


CHAPTER  VII 

THE  UTERUS— ITS  NORMAL  POSITION  AND  RELA- 
TIONS, ITS  ABNORMALITIES  OF  POSITION 
AND  DISEASES 

At  birth,  the  uterus  lies  high  in  the  pelvis,  its  axis  is  straight, 
and  it  is  normally  pressed  backward.  During  childhood  it 
gradually  sinks  deeper  in  the  pelvis.     The  normal  angulation 


r''i-       .J     /-  f  atrcnhied  lower  poftim 
•  bartners  d^cT.  of  Wolffian  duct) 


Pig.   40. — Diagram  of  the  uterus  and  vagina,  and  the  structures  of  the 
broad  ligament.      (Kelly  after  Cidlen.) 

between  the  body  and  the  cervix  does  not  appear  until  near 
puberty.  The  uterus  grows  in  size  for  some  years  after 
puberty.  Childbearing  increases  its  size  in  all  dimensions 
by  about  i  cm.  and  its  weight  about  25  grams. 


.ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  lOI 

The  virgin  uterus  is  normally  7  to  8  cm.  long  and  weighs  50 
grams.     The  natural  position  in  the  adult,  in  the  standing  posi- 


PlG.   41. — Normal  position  of  the  uterus.      (Ashton.) 


Pig.   42. — Normal  position  of  the  uterus,  seen  from  above. 

tion,  is  horizontal,  its  axis  meeting  the  vaginal  axis  at  an  angle 
of  90  degrees.  The  anterior  wall  lies  on  the  back  wall  and 
fundus  of  the  bladder;  on  the  posterior  wall  rest  the  intestines. 


102  ■  THE    UTERUS 

It  can  change  its  position  through  wide  Hmits;  it  may  be 
rotated  backward  through  an  angle  of  i8o  degrees;  laterally 
through  one  of  45  degrees,  to  each  side;  it  moves  backward  and 
forward  with  every  breath,  is  pushed  far  back  when  the  bladder 
is  full;  and  on  straining,  it  is  pushed  to  a  lower  level  in  the 
pelvis. 

How  Retained  in  Position. — By  (i)  the  support  of  the  peri- 
neum, (2)  intra-abdominal  pressure,  exerted  on  the  posterior 
wall,  keeping  it  normally  anteverted;  (3)  the^uterine  ligaments, 
which  are  partly  suspensory  and  partly  guy-ropes. 

Ligaments  of  the  uterus  are  ten  in  number — five  pairs,  (i) 
Two  broad  ligaments — the  folds  of  peritoneum  at  either  side; 

(2)  two  round— horn  each  cornu  to  the  internal  inguinal 
rings  and  thence  down  the  inguinal  canal  to  the  pubic  spine; 

(3)  two  uterosacral;  (4)  two  uterovesical,  though  commonly  fused 
so  as  to  appear  one;  (5)  two  cardinal — bands  of  connective 
tissue  in  the  parametrium  in  the  bases  of  the  broad  ligaments, 
running  from  about  the  level  of  the  internal  os,  through  the 
bases  of  the  broad  ligaments  to  fuse  with  the  fascia  on  the 
lateral  pelvic  wall.. 

Peritoneal  coat  of  the  uterus  (perimetrium)  covers  the 
posterior  wall,  above  the  level  of  the  internal  os;  the  fundus; 
the  anterior  wall  as  far  as  the  attachments  of  the  bladder.  It 
is  tightly  adherent  everywhere  except  on  the  anterior  and 
posterior  surfaces  of  the  lower  uterine  segment. 

The  parametrium  is  the  connective  tissue  in  the  base  of 
the  broad  ligaments  and  under  the  anterior  and  posterior 
peritoneal  reduplications — -in  Douglas'  pouch  and  behind  the 
bladder. 

The  myometriimi  is  the  uterine  muscle— arranged  in 
three  layers  and  unstriped. 

The  endometriimi  is  the  mucous  membrane  layer  lining 
the  cavity.  It  has  no  submucosa.  It  is  1-2  mm.  thick,  com- 
posed of  a  spindle-celled  connective  tissue  strewn  with  many 
tubular  glands,  lined  by  ciliated  columnar  epithelium.  The 
epithelium    of    the   body    differs   from    that    of    the    cervix. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  lO,^ 

The  cervical  cells  are  long,  thin,  with  nuclei  at  the  bot- 
tom. The  corporal  cells  are  short,  fat,  with  nuclei  in  the 
center.     The  cilia  lash  toward  the  os  uteri. 

The  uterus  during  lactation  is  much  smaller  than  normal,  a 
temporary  condition  due  to  shrinking  of  the  muscle  fibers. 
Any  curetment  done  after  miscarriage  or  during  lactation, 
causes  an  extra  risk  of  perforation  of  the  uterus. 

When  lactation  ceases,  the  uterus  returns  to  its  normal 
size. 

The  uterus  after  the  menopause  is  permanently  atrophied, 
its  axis  is  straight,  and  its  mucosa  atrophied. 

ABNORMALITIES  AND  DISEASES  OF  THE  UTERUS 

Anterior  Displacement  :  Anteflexion,  Anteversion, 
Anteposition 

anteflexion  of  the  uterus 

Anteflexion  of  the  uterus  is  an  increase  in  the  normal 
angulation  between  the  cervix  and  corpus  uteri.  It  is  often 
associated  with  ill-development  of  the  uterus  and  stenosis 
of  the  cervical  canal.  It  is  essentially  a  condition  of  nulli- 
parae only. 

Causes. — Unless  it  is  caused  by  the  pull  of  adhesions  or  a 
tumor  behind  the  uterus  (both  of  which  are  rare)  the  condition 
is  congenital,  due  to  faulty  development. 

Symptoms. — (i)  Dysmenorrhea,  the  pain  being  most  severe 
for  the  first  twenty-four  hours  of  the  period,  and  gradually 
subsiding  as  the  flow  is  established;  (2)  a  brown  leukorrhea, 
at  the  end  of  the  period,  due  to  slow  draining  of  retained  blood; 
(3)  sterility;  (4)  in  many  cases,  pronounced  neurotic  symptoms. 

Diagnosis. — If  the  examining  finger  is  passed  along  the 
anterior  wall  of  the  cervix,  and  pressed  deeply  into  the  anterior 
vaginal  vault,  the  sharp  U-shaped  bend  can  be  felt;  bimanual 
examination  reveals  the  anterior  position  of  the  uterus; 
specular  examination  shows  a  long  conical  cervix  and  a  pin- 
hole OS  uteri. 


I04  THE    UTERUS 

Treatment. — The  most  satisfactory  treatment  is  forcible 
dilatation  of  the  cervical  canal,  thus  straightening  out  the  axis, 
followed  by  Schatz's  metranoikter,  left  in  place  for  24  hours. 

Technic. — (i)  The  patient  is  prepared  as  for  any  vaginal 
operation,  arranged  in  the  dorsal  position  and  anesthetized. 

2.  The  anterior  lip  of  the  cervix  is  caught  with  a  double 
tenaculum  and  held  by  an  assistant. 


Pig.  43. — Anteflexion  of  the  utertis.      A  lateral  view. 

3.  The  cervical  canal  is  dilated  with  a  light  Goodell  dilator, 
just  enough  to  admit  the  blades  of  the  heavy  Wathen  dilator. 
In  very  tight  stenosis,  the  internal  os  must  be  first  penetrated 
with  a  probe  and  then  a  uterine  sound  before  the  light  dilator 
can  be  inserted. 

4.  With  a  heavy  Wathen  dilator  the  cervix  is  dilated  to  one 
inch  transverse  measurement,  making  pressure  by  the  side 
screw  of  the  instrument  and  never  by  pressing  the  handles 
together,  nor  should  the  instrument  be  rotated  from  side 
to  side.  Ten  minutes  should  be  taken  to  reach  the  one  inch 
mark,  to  avoid  tearing. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS 


105 


5.  With  a  four-bladed  Cleveland  dilator,  a  dilatation  of  go 
mm.  circumference  is  now  secured. 

6.  No  curettage  is  desirable,  unless  the  patient  has  leukor- 
rhea.  If  done,  it  is  performed  gently,  with  a  sharp  Sims  curet. 
Dull  curets  are  useless  here. 

7.  The  uterus  is  washed  out  with  sterile  water. 

8.  The  two-bladed  Schatz  metranoikter,  or  better  its 
four-bladed  B.  C.  Hirst  modification,  is  inserted  in  the  uterine 
canal,  as  far  as  it  will  go,  and  the  vagina  packed  with  gauze. 


Pig.  44. — Replacing  uterus  in  proper  position  after  curettement.     If  this 
is  neglected,  permanent  retroversion  may  result.      {After  Crossen.) 


9.  Twenty-four  hours  later,  the  metranoikter  is  removed, 
and  the  uterus  washed  out  with  sterile  water,  this  lavage  is 
most  essential. 

10.  The  patient  is  kept  in  bed  for  one  week. 

About  half  the  patients  require  a  dose  of  3^^  grain  morphin 
sulphate  hypodermically  during  the  night  following  operation, 
due  to  pain  from  pressure  of  the  metranoikter. 


Io6  THE    UTERUS 

Alternate  Methods  of  Treatment. — (i)  The  Wylie  drain  is 
often  used  in  place  of  the  metranoikter.  It  is  a  plug  of 
aluminum  or  hard  rubber,  channeled  to  permit  escape  of 
discharge.  It  is  inserted  in  the  uterine  canal  at  the  point 
where  by  the  above  technic  the  Schatz  instrument  is  used. 
It  is  not  as  efficient  as  the  metranoikter,  has  some  risk  of 
infection  of  the  endometrium  and  pyosalpinx,  and  fatal 
infection  has  followed  its  use.  From  all  these  objections, 
the  metranoikter  has  proven 'itself  free.  One  of  these  instru- 
ments must  be  used,  however,  to  secure  satisfactory  permanent 
dilatation.  The  simple  instrumental  dilatation  is  not 
permanent. 

(2)  Tents. — Plugs  of  compressed  sponge  or  tupelo  wood, 
designed  to  absorb  moisture  after  being  inserted  in  the  uterine 
canal,  and  by  their  swelling  to  dilate  the  cervix,  have  fallen 
into  deserved  disrepute.  They  cannot  be  satisfactorily 
sterilized. 

(3)  Dudley's  operation  is  discission  of  the  posterior  cervical 
lip,  through  the  internal  os,  and  se\ving  the  wound  trans- 
versely, to  cause  gaping.  It  is  efficient  in  relieving  the  stenosis, 
but  is  often  followed  by  annoying  leukorrhea  from  endo- 
cervicitis  and  erosion,  and  may  require  repair  of  the  cervix 
or  even  amputation. 

Palliative  treatment,  of  a  condition  which  is  largely 
mechanical,  is  usually  a  waste  of  time,  and  often  a  real  danger, 
due  to  the  use  of  habit-forming  drugs.  For  temporary  use, 
the  following  will  be  found  useful,  but  not  over  long  periods. 

(i)  Rest  in  bed  during  the  first  two  days  of  the  period; 
(2)  hot  water  bag  to  lower  abdomen ;  (3)  hot  vaginal  douches 
(11 5'-!  20')  three  times  daily  (hot  enemata  in  young  single 
women);  (4)  tincture  of  gelsemium,  TUx  four  times  daily; 
(5)  acetanilid  gr.  2,  ammonium  carbonate  gr.  3  every 
three  hours;  (6)  if  stronger  sedatives  are  needed,  codein 
sulphate  gr.  3^^  hypodermically  and  not  morphin. 

Pessaries  for  anteflexion  are  practically  useless.  The  intra- 
uterine stem  pessary  of  any  form  is  dangerous  because  of  infec- 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  tO'J 

tion;  Schultz's  sleigh,  Thomas'  anteversion  and  Hewitt's 
cradle  pessaries  are  all  of  so  little  use  as  hardly  to  be  worth  a 
trial. 

ANTEVERSION  OF  THE  UTERUS 

Anteversion  of  the  uterus  is  its  normal  position,  and  the  use 
of  this  term  to  describe  a  pathologic  condition  is  erroneous. 

ANTEPOSITION  OF  THE  UTERUS 

Anteposition  of  the  uterus  is  the  pushing  forward  of  the  organ 
by  a  tumor  or  abscess  behind  it,  or  is  due  to  the  pull  of  adhe- 
sions. The  symptoms  are  dysuria  and  irritability  of  the 
bladder,  due  to  pressure.  When  the  cause  is  removed,  the 
uterus  resumes  its  normal  position. 

The  irritability  of  the  bladder  in  early  pregnancy  is  due  to 
pressure  from  anteposition  of  the  uterus,  because  the  increased 
weight  of  the  body  and  greater  flexibility  of  the  lower  uterine 
segment  permit  the  uterus  to  fall  forward  on  the  bladder. 

Lateral  flexion  of  the  uterus  is  due  to  (i)  adhesions;  (2) 
pressure  of  a  growth;  (3)  congenital  deformity  (uterus  uni- 
cornis). 

Backward  Displacement  of  the  Uterus  :  Retroflexion 
AND  Retroversion 

In  retroversion,  the  uterus  is  turned  back  as  a  flail;  in 
retroflexion,  it  is  bent  back  at  the  lower  uterine  segment. 
Except  for  the  position  of  the  cervix,  which  in  retroversion 
is  often  further  anterior,  the  two  conditions  are  practically 
identical  in  causes,  symptoms  and  treatment,  and  will  be  so 
considered. 

Causes. — (i)  Congenital,  where  the  uterus  has  developed 
in  the  posterior  position;  (2)  relaxation  of  the  uterine  supports 
or  musculature;  (3)  the  drag  of  adhesions;  (4)  pushed  back 
by  a  tumor. 

By  far  the  greatest  number  of  cases  follow  childbirth,  and 
hence  belong  under  the  second  head. 


I08  "       THE    UTERUS 

Predisposing  causes  are:  (i)  Violent  jars  or  falls,  producing 
a  traumatic  displacement,  which  may  be  permanent  if  neg- 
lected; (2)  long-continued  overfilling  of  the  bladder;  (3) 
perineal  lacerations;  (4)  subinvolution  of  the  uterus  after 
childbirth. 

Time  of  occurrence  is,  in  the  cases  following  childbirth, 
most  commonly  between  the  third  and  sixth  weeks  of  the 
puerperium. 

Symptoms.-^(i)  Backache,  low  down  over  sacrum,  and 
always  central;  (2)  headache,  most  marked  over  the  vertex  or 
occiput;  (3)  pelvic  pain,  on  one  or  both  sides,  due  to  conges- 
tion from  torsion  of  the  broad  ligaments;  (4)  increased  men- 
strual flow;  (5)  often  dysmenorrhea;  (6)  nervous  irritability; 
(7)  leukorrhea.  The  backache  and  headache  are  usually  re- 
lieved on  lying  down;  all  symptoms  are  more  marked  at  the 
menstrual  periods.  None  of  the  symptoms  are  constant,  and 
many  women  with  retroversion  exhibit  no  symptoms  whatever. 

Diagnosis  is  made  by  bimanual  examination,  with  the  pa- 
tient in  the  dorsal  position,  preferably  on  a  table.  It  is 
absolutely  essential  that  the  bladder  be  empty;  a  full  bladder 
temporarily  pushes  the  uterus  backward  and  may  cause  a 
mistaken  diagnosis. 

I.  With  the  patient  in  the  dorsal  position,  two  fingers  of 
one  hand  are  placed  in  the  vagina,  with  the  finger  tips  in 
front  of  the  cervix;  (2)  with  the  free  hand,  pressure  is  made 
on  the  abdomen,  in  the  middle  line,  just  above  the  symphysis; 
(3)  if  the  uterine  body  is  in  good  position,  it  can  be  felt  between 
the  fingers.  If  not,  the  fingertips,  provided  the  patient  is  not 
fat  and  does  not  resist,  will  meet  with  only  the  tissues  of  the 
abdominal  wall  and  vaginal  vault  between  them;  (4)  the 
fingers  of  the  vaginal  hand  are  then  moved  behind  the 
cervix,  and  the  body  of  the  uterus  can  be  felt  posteriorly.  The 
use  of  a  sound  for  diagnosis  of  position  is  unnecessary  and 
dangerous. 

Degrees  of  Retroversion. — First  degree — with  the  fundus 
tilted  away  from  the  bladder;  second  degree,  with  the  fundus 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS 


109 


pointing  about  to  the  middle  of  the  sacrum;  third  degree, 
with  the  fundus  completely  back  in  Douglas'  pouch. 

Differential  Diagnosis. — The  commonest  error  is  to  mistake 
an  anteflexed  uterus,  with  retrocession,  for  a  retroversion. 
The  sharp  anterior  angle  of  flexion  can  always  be  felt;  (2) 
myoma;  (3)  ovarian  cyst;  (4)  dense  pyosalpinx  adherent 
in  Douglas'  pouch. 

Rectal  examination  is  often  required  in  (i)  young  girls, 
(2)  when  patient  resists  vaginal  examination.  The  cervix 
feels  considerably  larger  by  a  rectal  than  by  vaginal  examina- 


FiG.  45. — Diagram  illustrating  the  three  degrees  of  retroversion  of  the 
uterus.  The  third  degree  is  often  called  complete  retroversion.  {After 
Skene.) 


tion.     In  any  case  of  doubt,  examination  under  anesthesia  is 
required. 

Pathology. — (i)  The  uterus  is  large,  heavy  and  softer  than 
normal;  (2)  it  has  a  deep  purple,  mottled  color,  from  chronic 
congestion;  (3)  varicocele  of  the  broad  ligament  is  common; 
(4)  the  endometrium  is  hypertrophied;  (5)  the  tubes  are 
congested;  (6)  the  ovaries,  being  in  secondary  prolapse  in 
Douglas'  pouch,  with  the  uterus  lying  on  top  of  them,  show 
a  tendency  to  cystic  formation;  (7)  adhesions  are  rare,  except 
as  a  result  of  infection. 


no  THE    UTERUS 


TREATMENT 


Treatment  may  be  (i)  palliative  or  (2)  operative.  Cases 
which  exhibit  no  symptoms  require  no  treatment.  Cases 
which  show  a  tendency  to  abort,  or  there  is  associated  sterility, 
require  correction,  even  though  no  other  symptoms  are 
present. 

Palliative  Treatment. — Indications:  (i)  Recent  traumatic 
retroversion;  (2)  retroversion  shortly  after  childbirth;  (3) 
non-adherent  retroversion,  where  the  patient  makes  the 
choice;  (4)  certain  cases  of  adherent  retroversion  (treated  by 
tampons). 

A  recent  traumatic  case  (from  a  fall  or  severe  jar)  requires 
only  reposition,  under  anesthesia  if  necessary,  and  no  method 
of  mechanical  support  is  needed.  As  soon  as  the  uterus  is 
freed  from  the  pressure  of  the  uterosacral  ligaments,  between 
which  it  is  caught,  it  resumes  its  normal  position  and  stays 
there.  Reposition  in  these  cases  is  best  done  by  rectal 
pressure. 

Methods  of  Reposition.  I.  Bimanual — (i)  The  patient  is 
arranged  on  a  table,  not  a  bed,  in  the  dorsal  position. 

2.  Two  fingers  of  one  hand  are  placed  in  the  vagina,  behind 
the  cervix. 

3.  The  uterine  body  is  lifted,  by  these  fingers,  until  the 
fingers  of  the  other  hand,  on  the  abdomen,  can  catch  behind 
the  fundus  and  pull  it  forward.  This  maneuver  can  be  as- 
sisted materially  by  a  double  tenaculum  catching  the  anterior 
lip  of  the  cervix.  It  will  not  succeed  if  the  uterus  is  adherent, 
if  the  patient  is  fat  or  if  she  resists  the_  examination. 

II.  Reposition  in  the  Knee-chest  Posture. — (i)  The  patient 
is  arranged  in  the  knee-chest  posture,  on  a  table;  (2)  the 
perineum  is  retracted  by  a  Sims  speculum;  (3)  the  anterior 
lip  of  the  cervix  is  caught  with  a  double  tenaculum;  (4)  with 
a  repositor,  in  the  posterior  vaginal  vault,  the  uterine  body  is 
pried,  not  pushed,  forward,  as  the  double  tenaculum  on  the 
cervix  is  pulled  down. 


.ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  III 


Fig.  46. — ^The  different  steps  in  bimanual  reposition  of  a  retroverted 
uterus.  This  is  only  possible  when  the  patient  is  thin,  relaxed,  and  the 
uterus  is  not  adherent. 


112  ■  THE    UTERUS 

III.  Rectal  manipulation  is  often  of  value  in  both  the  above 
methods.  It  is  best  carried  out  with  a  curved,  heavy  sound; 
the  finger  is  too  short  for  the  purpose. 

IV.  The  uterine  sound  or  more  safely,  a  small  intra-uterine 
Bozemann  douche  nozzle  may  be  used,  in  cases  which  cannot 
be  replaced  by  other  methods,  provided  extreme  asepsis  and 
gentleness  be  observed.  For  this  method  the  uterus  must 
not  he  adherent.  A  bivalve  speculum  is  inserted  in  the  vagina 
and  the  cervix  exposed;  the  cervix  is  wiped  off  with  pledgets 
of  cotton  soaked  in  i-iooo  bichlorid  solution;  the  sound,  bent 
in  a  good  curve,  or  the  douche  nozzle — ^if  there  is  sufi&cient 
dilatation  of  the  cervix — is  passed  into  the  uterine  canal  and 
the  uterus  gently  pried  forward.  This  method  is  useful  in 
very  fat  women,  but  must  be  cautiously  used  and  all  instru- 
ments boiled. 

V.  Anesthesia  may  be  required  in  any  of  the  above  methods. 

VI.  Adherent  retroversion  may  sometimes  be  replaced  by 
the  following  method:  (i)  The  patient  is  arranged  in  the  knee- 
chest  posture,  on  a  table;  (2)  the  perineum  is  retracted  by  a 
Sims  speculum;  (3)  a  small,  wool  tampon  is  grasped  with 
placental  forceps,  dusted  with  boric  acid  powder,  and  placed 
in  the  posterior  vaginal  vault  with  as  much  pressure  as  the 
patient  can  stand;  (4)  other  tampons  are  placed  below  this, 
until  the  vagina  is  full.  A  count  is  kept  of  the  number  used. 
(5)  The  tampons  are  removed  by  the  patient,  after  forty-eight 
hours.  She  takes  a  vaginal  douche,  and  returns  to  the  office 
for  a  fresh  supply.  (6)  The  treatment  lasts  ten  or  twelve 
weeks,  being  interrupted  during  menstruation.  If  the 
patient  has  the  patience  to  persist,  this  method  is  often 
successful. 

Pessaries. — After  a  uterus  is  replaced,  if  it  will  not  remain 
in  place  without  support,  it  may  be  kept  in  proper  position 
by  a  pessary.  Except  in  cases  immediately  following  the 
puerperium,  a  pessary  is  not  a  cure,  simply  a  crutch,  but 
patients  can  be  kept  comfortable  for  as  long  as  they  choose 
to  wear  it.     The  pessary  requires  regular  inspection  every  six 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS         II3 

to  eight  weeks,  must  then  be  removed,  cleaned  and  replaced, 
and  if  the  vaginal  vault  shows  any  sign  of  erosion,  it  must  be 
left  out  for  two  to  four  weeks  and  the  erosion  treated  by- 
vaginal  douching  and  boroglycerid  tampons. 

Kinds  of  Pessaries. — (i)  Hodge — with  a  broad  lower  bar, 
usually  uncomfortable  because  of  pressure  on  the  urethra, 
but  valuable  when  there  is  slight  relaxation  of  the  outlet. 
(2)  Smith,  narrower  at  its  lower  end,  and  the  most  comfortable 
type.  (3)  Thomas — the  same  shape  as  the  Smith,  but  with  a 
very  heavy  upper  bar,  to  span  the  angle  of  flexion  in  retro- 


Hodge  Smith  Thomas 

Pig.  47. — The  three  types  of  retroversion  pessary  in  common  use. 

flexion.  Pessaries  are  made  of  hard,  vulcanized  polished 
rubber. 

How  Retained: — (i)  The  fit  of  the  shaped  pessary  to  the 
vaginal  canal;  (2)  the  cervix,  behind  which  the  upper  bar  is 
hooked;  (3)  the  pressure  of  the  perineum;  (4)  the  elastic  and 
muscular  tissues  of  the  vaginal  walls. 

How  it  Acts: — As  a  lever  in  the  vagina,  the  force  of  the  short 
(upper)  arm  of  the  lever  behind  the  cervix  being  exerted 
on  the  uterosacral  ligaments  and  posterior  vaginal  vault. 
This  pulls  the  cervix  up  and  back  and  tilts  the  fundus  forward. 

Indications  for  a  Pessary. — (i)  Uterus  free  from  adhesions; 
(2)  a  patient  able  to  abstain  from  hard  work;  (3)  uterus  re- 
placeable and  in  place  when  the  pessary  is  inserted;  (4)  good 
perineal  support  (if  the  perineum  is  torn,  the  pessary  will 
drop  out  as  soon  as  the  patient  stands  up) ;  (5)  ovary  must 
not  be  prolapsed. 


114 


THE    UTERUS 


Contra-huiicaiions,~~{i)  A  patient  who  must  do  hard  work; 
(2)  adherent  retroversion;  (3)  prolapse  of  the  ovary;  (4)  a 
uterus  that  cannot  be  replaced;  (3)  young  single  women  (due 
to  the  narrow  vagina  and  consequent  difficulty  of  insertion 
and  after  care). 

A  pessary  should  never  be  inserted  with  the  hope  that  it 
will  pry  the  uterus  into  proper  position. 

Insertion  of  a  Pessary.- — (i)  The  patient  is  in  the  dorsal 
position;  {2)  the  uterus  is  in  proper  position;  (3)  the  pessary 


Fig.  48. — The  first  step  in  the  insertion  of  a  pessary.     {After  B.  C.  Hirst.) 

is  grasped  by  the  lower  bar  and  greased  (glycerin);  (4)  the 
forefinger  of  one  hand  presses  down  in  one  vaginal  sulcus; 
(5)  the  pessary  is  inserted  obliquely  in  this  sulcus,  and  upside 
down>  for  about  one-half  its  length;  (6)  the  pessary  is  turned 
right  side  up;  (7)  the  forefinger  of  the  other  hand  makes 
pressure  on  the  upper  bar  of  the  pessary,  carrying  it  up  and 
behind  the  cervix  (never  in  front  of  the  cervix). 

Qualifications  for  Proper  Pessary. — (i)  No  portion  of  it  is 
visible  after  insertion.  (If  so  it  is  too  long,  and  can  be  short- 
ened by  increasing  the  curvature.)     (2)  It  should  reach  from 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS         II 5 

the  posterior  vaginal  vault  to  the  anterior  vaginal  wall,  at 
the  level  of  the  internal  urinary  meatus.  (3)  There  should  be 
room  to  pass  the  finger  all  around  it.  (4)  It  should  be  the 
smallest  that  will  satisfactorily  support  the  uterus.  (5) 
It  should  cause  no  pain.  (6)  It  does  not  interfere  with  coitus. 
(7)  In  cases  of  retroflexion  the  Thomas  pessary  is  used  to 
span  the  angle  of  flexion. 

It  is  not  usually  possible  to  find  at  the  first  trial  a  pessary 
satisfactory  in  all  respects.     The  instrument  must  be  fitted 


Pig.   49. — The  pessary  in  position.      {After  Skene.) 


to  each  case.  The  shape  of  the  pessary  can  be  varied  by 
immersing  in  boiling  water,  moulded  to  the  desired  shape, 
and  then  plunged  in  cold  water  to  harden  it. 

After-treatment. — The  patient  is  told  to  report  in  two  weeks, 
or  sooner  if  she  is  uncomfortable.  She  then  reports  every 
four  weeks,  for  three  months.  At  each  visit,  the  pessary  is 
removed  by  hooking  the  forefinger //'ow  helow,  under  the  lower 
bar;  the  vaginal  vaults  are  inspected  through  a  bivalve  specu- 
lum for  possible  erosion  or  irritation,  and  if  none  is  found, 


Il6  *  THE   UTERUS 

the  pessary  is  reinserted.  After  three  months,  an  attempt 
is  made  to  do  without  the  pessary,  for  two  weeks;  if  the  uterus 
is  found  in  good  position,  and  again  four  weeks  later,  the 
patient  may  be  discharged  as  cured.  If  the  displacement 
recurs,  the  pessary  is  again  inserted  for  three  months,  with 
examination  as  before.  If  then,  after  the  pessary  has  been 
worn  for  six  months,  the  uterus  will  not  stay  in  place  without 
support,  the  patient  is  given  her  choice  between  the  constant 
wearing  of  a  pessary  or  operation.  During  the  period  of 
trial,  the  patient  may  undergo  a  course  of  pelvic  massage  and 
Swedish  movements,  designed  to  strengthen  the  pelvic  muscles 
and  ligaments,  but  of  doubtful  value. 

The  long-continued  wearing  of  a  pessary  is  not  desirable. 
It  requires  constant  watching,  the  pressure  of  it  is  irritating, 
it  tends  to  aggravate  any  neurosis  of  the  patient,  and  to 
convince  the  patient  that  she  requires  constant  medical  atten- 
tion. Frequent  vaginal  douching  while  the  pessary  is  worn 
is  not  advisable;  a  douche  of  salt  solution  twice  a  week  is 
ample. 

Operative  Treatment  for  Backward  Displacement  of  the 
Uterus. — Indications:  (i)  Adherent  retroversion,  when  the 
uterus  cannot  be  replaced;  (2)  a  patient  who  must  do  hard 
work;  (3)  as  an  operation  of  election,  after  a  pessary  has  been 
tried  and  has  failed  to  keep  the  uterus  in  position;  (4)  when  a 
pessary  cannot  be  worn,  due  to  the  irritation  it  produces  in 
the  vagina;  (5)  in  cases  with  associated  tendency  to  abortion 
or  with  sterility,  even  though  other  symptoms  are  absent. 

The  ideal  operation  is  one  that  (i)  is  free  from  risk;  (2)  does 
not  open,  or  entails  a  minimum  of  invasion  of  the  peritoneal 
cavity;  (3)  has  a  minimum  of  recurrences;  (4)  does  not  add 
any  difficulty  in  future  childbirth;  (5)  withstands  subsequent 
childbirth. 

As  eighty-one  different  technics  have  so  far  been  devised, 
it  is  obvious  that  no  single  operation  answers  all  these  factors. 
Those  of  most  value  are  described  below. 

I.  Alexander  operation  ( Adams- Alquie-Edebohl's)  the  princi- 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS         II 7 

pie  of  which  is  the  extraperitoneal  shortening  of  the  round 
ligaments  in  the  inguinal  canal. 

Indications. — (i)  Non-adherent  retroversion,  without  suspi- 
cion of  pelvic  disease  or  appendicitis;  (2)  patient  preferably 
under  thirty-five;  (3)  patient  not  too  fat. 

Advantages. — (i)  Extraperitoneal;  (2)  negligible  percentage 
of  failure;  (3)  never  any  trouble  in  subsequent  childbirth; 
(4)  withstands  subsequent  childbirth. 

Disadvantages. — (i)  Does  not  permit  inspection  of  the  pelvic 
organs  or  appendix;  (2)  unsuspected  pelvic  adhesions  may 
cause  subsequent  pain;  (3)  inguinal  hernia — this  danger  largely 
theoretical,  as  the  operation  properly  done  is  really  a  Bassini 
for  hernia. 

The  greatest  disadvantage  of  the  Alexander  operation  can  be 
avoided  by  opening  both  internal  rings,  after  the  ligaments 
are  found  and  stripped  out.  Adhesions  can  be  broken  up,  the 
tubes  inspected  and  the  appendix  removed.  When  the 
adhesions  are  very  dense  or  pyosalpinx  exists,  this  is  not  appli- 
cable, but  for  cases  without  gross  pathologic  lesions  it  is 
nearly  ideal.  The  peritoneum  of  the  rings  is  closed  separately, 
and  the  rings  themselves  closed  as  the  round  ligaments  are 
sewed  fast. 

Causes  of  Failure. — (i)  Infection;  (2)  failure  to  puU  out 
enough  round  ligament;  (3)  in  a  small  percentage  of  cases, 
the  round  ligaments  are  too  thin  to  give  proper  support,  and 
very  rarely  they  are  entirely  absent. 

Very  rarely  the  round  ligaments  run  from  the  internal  ring 
to  the  anterior-superior  spines,  instead  of  the  pubic  spines, 
a  fact  to  be  remembered  when  they  cannot  be  found  in  their 
normal  situation. 

Technic. — (i)  The  patient  is  prepared  as  for  any  section, 
and  anesthetized.  The  operation  is  not  satisfactory  under 
local  anesthesia. 

2.  An  incision  is  made  parallel  to  the  upper  border  of 
Poupart's  ligament,  for  a  distance  of  two  or  three  inches  from 
the  pubic  spine.     This  is  extended  through  the  superficial 


Il8  .   .         THE    UTERUS 

fascia  and  fat  until  the  fascia  covering  the  inguinal  canal  is 
exposed.  All  bleeding  vessels  are  caught  'and  tied,  as  the 
wound  must  be  dry. 

3.  Midway  between  the  pillars  of  the  external  ring,  the 
fascia  over  the  inguinal  canal  is  cut,  in  the  same  line  as  the  skin 
incision. 

4.  The  edges  of  the  fascia  are  retracted  with  hooked  retract- 
ors, and  the  round  ligament  is  picked  up  on  a  blunt  hook, 
from  its  position  along  the  floor  of  the  canal.  The  ilio-inguinal 
nerve  lies  just  above  it.  The  ligament  can  be  recognized, 
when  it  is  lifted,  by  its  white  color. 

5.  The  band  of  cremasteric  fascia,  running  along  the  liga- 
ment is  cut,  and  the  ligament,  by  blunt  dissection  with  a  pad, 
is  stripped  out  of  the  internal  ring  for  six  or  eight  inches. 

6.  The  wound  is  covered,  and  the  opposite  groin  opened  and 
the  ligament  stripped  out  in  the  same  way. 

7.  Both  ligaments  are  then  pulled  tense,  crossed  over  the 
symphysis,  and  a  hemostat  clamped  at  the  point  of  intersec- 
tion. The  fundus  can  be  felt  to  bump  against  the  anterior 
abdominal  wall,  as  the  ligaments  are  pulled  on. 

8.  The  hgaments  are  then  sewed  into  the  canal  with  a 
continuous  stitch;  each  bite  of  the  needle  taking  in  turn:  (i) 
The  upper  edge  of  Poupart's  ligament;  (2)  the  floor  of  the 
inguinal  canal;  (3)  the  middle  of  the  round  ligament  (so  as 
not  to  strangulate  it);  (4)  the  external  oblique  muscle;  (5) 
the  external  oblique  fascia.  Number  i  chromic  catgut  is  used, 
and  the  stitch  ends  at  the  pubic  spine,  closing  the  external 
ring. 

9.  The  excess  of  ligament  is  cut  off. 

10.  The  skin  and  fat  is  closed  as  in  any  operation. 

11.  For  six  weeks  it  is  desirable,  except  in  young  unmarried 
women,  to  have  the  uterus  supported  by  a  pessary. 

II.  Alexander  operation,  with  Pfannenstiel  incision  is  designed 
to  utilize  the  principle  of  the  Alexander  operation  and  at 
the  same  time,  permit  inspection  of  the  appendages  and 
appendix. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  II9 

Disadvantages. — (i)  It  is  exceedingly  difficult  to  remove  a 
badly  adherent  appendix,  on  account  of  limited  room;  (2)  deep- 
seated  hematomata  are  not  uncommon,  due  to  the  extensive  dis- 
section; (3)  there  is  some  danger  of  injury  to  the  bladder,  in  open- 
ing the  peritoneum,  as  the  wound  is  very  near  the  symphysis. 

Advantages. — (i)  It  permits  inspection  or  removal  of  tubes, 
ovaries  and  appendix;  (2)  unsuspected  adhesions  can  be  dealt 
with;  (3)  the  scar  is  almost  entirely  hidden  in  the  pubic  hair; 
(4)  it  withstands  subsequent  childbirth,  due  to  the  Alexander 
principle. 

Technic. — (i)  The  patient  is  prepared  as  for  any  section  and 
anesthetized. 

2.  The  Pfannenstiel  semilunar  incision  is  made  down  to  the 
fascia. 

3.  The  inguinal  canals  are  opened,  and  the  round  ligaments 
dissected  out,  as  in  the  Alexander  operation. 

4.  The  two  groin  fascia  wounds  are  then  connected  above 
the  symphysis,  the  pyramidahs  muscles  cut  loose,  the  rectus 
muscles  separated  and  the  peritoneum  opened  in  the  middle 
line,  by  a  vertical  incision. 

5.  The  appendages  and  appendix  are  inspected,  adhesions,  if 
any,  broken  up  and  the  uterus  suspended  by  a  single  stitch 
of  plain  number  3  catgut,  to  act  as  a  pessary. 

6.  The  peritoneum  is  closed. 

7.  The  round  ligaments  are  sewed  fast,  as  in  the  Alexander 
operation. 

8.  The  rectus  and  pyramidalis  muscles  are  repaired  and  the 
fascia,  fat  and  skin  closed  as  in  any  operation. 

III.  Combined  Alexander  and  Section. 

Indications. — (i)  Cases  where  the  uterus  is  adherent,  the 
patient  is  not  too  fat,  and  is  under  thirty-five.  Past  this  age, 
the  round  ligaments  are  often  atrophied,  and  the  risk  of 
failure  considerably  increased. 

Advantages. — Permits  thorough  inspection  of  tubes  and 
ovaries  and  appendix,  and  allows  proper  management  of  any 
gross  pathologic  lesion. 


I20  ■  THE    UTERUS 

Disadvantages. — None,  except  the  theoretical  one  of  three 
incisions,  which,  however,  involve  no  mutilation  or  exten- 
sive dissection,  and  leave  the  patient  in  normal  anatomical 
condition. 

Technic. — (i)  The  patient  is  prepared  as  for  any  section 
and  anesthetized;  (2)  both  groins  are  protected  with  gauze 
sponges,  soaked  in  70  per  cent,  alcohol;  (3)  a  short  central 
incision  is  made  and  any  necessary  pelvic  work  done.  The 
round  ligaments  are  inspected,  to  make  sure  they  are  suflS- 
ciently  thick  and  the  abdomen  closed  at  once ;  (4)  the  abdom- 
inal wound  is  covered  with  gauze  and  from  this  point  the 
technic  is  the  same  as  the  Alexander  operation.  For  any 
case  where  future  childbearing  is  possible,  this  is  one  of 
the  most  satisfactory  operations  yet  devised. 

IV.  Ventro suspension  (Hysterorrhaphy;  Hysteropexy)  is 
the  suspension  of  the  uterus,  by  sutures,  against  the  anterior 
abdominal  wall,  just  above  the  symphysis. 

Advantages. — (i)  The  operation  is  quick  and  easy.  It  takes 
less  time  than  any  other  method.  (2)  In  patients  who  will 
never  bear  children,  it  is  satisfactory. 

Disadvantages. — (i)  It  pulls  the  uterus  out  of  the  pelvis; 
(2)  it  has  a  high  percentage  of  failures;  (3)  it  never  withstands 
subsequent  childbirth;  (4)  it  cramps  the  bladder  for  room; 
(5)  there  is  some  danger  of  intestinal  obstruction;  (6)  if  the 
wound  is  infected,  the  silk  or  Pagenstecher  stitches  cause  an 
annoying  sinus;  (7)  as  a  result  of  infection,  the  uterus  may 
be  fixed,  instead  of  suspended. 

The  uterus  does  not  remain  tight  against  the  abdominal  wall. 
In  a  few  weeks,  a  suspensory  ligament,  about  two  inches  long 
is  formed,  by  which  the  uterus  hangs  in  place.  If  the  sus- 
pensory stitches  take  in  the  fascia  of  the  anterior  abdominal 
waU,  the  result  is  a  ventrofixation  of  the  uterus,  which  is  to 
be  avoided  in  women  of  childbearing  age. 

Indications: — ^(i)  In  patients  past  the  danger  of  childbear- 
ing; (2)  in  ovarian  cyst  operations,  as  a  precaution  against 
secondary  retroversion;  (3)    as  an    adjuvant  in  round   liga- 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  121 

ment  operations;  (4)  in  all  other  cases,  with  appreciation  of 
the  risks  of  failure. 

Technic. — (i)  The  patient  is  prepared  as  for  any  section 
and  anesthetized;  (2)  the  abdomen  is  opened  in  the  midhne, 
and  all  necessary  work  done;  (3)  just  before  the  abdomen  is 
closed,  the  uterus  is  suspended  by  two  silk  or,  better,  Pagen- 
stecher  linen  thread  stitches  passed  through  the  peritoneum 
of  one  side  from  within,  through  the  inner  one-third  of  the 


Fig.  50. 


Fig.  51. 


Fig.  50. — The  suspension  stitch  in  ventro-suspension.  When  the  stitch 
is  tied,  and  the  flap  of  peritoneum  closed  over  it,  the  stitch  is  in  the  peri- 
toneal cavity,  and  less  likely  to  cause  a  persistent  sinus  should  the 
wound    become    infected.     (After  B.  C.  Hirst.) 

Fig.  51. — A  lateral  view  of  the  operation  of  ventro-suspension  of  the 
uterus  completed.  Notice  how  the  bladder  is  cramped  for  room.  {After 
Crossen.) 


rectus  muscle  and  down  through  the  peritoneum  again; 
through  the  fundus  uteri,  between  the  tubes,  taking  a  bite 
one-half  inch  wide  and  one-quarter  inch  deep;  through 
the  peritoneum  and  inner  one-third  of  the  rectus  muscle 
of  the  other  side  and  down  through  the  peritoneum  again. 
When  the  knots  are  tied,  they  will  be  inside  the  peritoneal 
cavity.  Catgut  is  not  satisfactory,  because  of  stretching 
and  premature  absorption.  One  stitch  passes  close  behind 
the  other   through   the  fundus.     If   they  are   too  far  apart, 


122 


THE    UTERUS 


two  suspensory  bands  may  result,  with  possible  intestinal 
obstruction;  (4)  an  assistant,  with  one  finger  in  the  wound 
behind  the  uterus,  keeps  intestines  out  of  the  way  until  the 
knots  are  tied;  (5)  the  abdomen  is  closed  in  the  ordinary  way. 
V.  Baldy  operation,  the  principle  of  which  is  pulling  the 
round  ligaments  through  the  broad  ligaments,  under  the 
ovarian  ligaments,  and  sewing  the  loops  together  behind  the 
uterus  in  the  middle  line,  fixing  them  to  the  uterus  as  well. 
The  Webster  operation  is  the  same  in  principle,  but  the  round 
ligaments  are  fastened  where  they  come  through  the  broad 


Fig.  52. 


-The   Baldy   operation  for  retroversion,   seen   from   above   and 
from  behind.      {After  Graves.) 


ligaments  instead  of  in  the  middle  line.  It  is  not  nearly  as 
satisfactory. 

Advantages. — (i)  Leave  the  uterus  in  normal  position;  (2) 
plenty  of  room  for  the  bladder;  (3)  utihzes  the  thick  ends  of 
the  round  ligaments;  (4)  ovaries  are  suspended. 

Disadvantages. — (i)  Extensive  adhesions  from  traumatism 
of  the  broad  ligaments  and  uterus;  (2)  some  difficulty  in  sub- 
sequent pregnancies,  with  added  risk  of  miscarriage;  (3) 
frequent  recurrence  of  retroversion  after  delivery. 

Indications. — -Any  case  of  retroversion  where  the  appendages 
do  not  require  removal,  and  the  uterine  attachments  of  the 
round  ligaments  are  not  interfered  with. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  12,-^ 

Technic. — (i)  The  abdomen  is  opened  in  the  middle  line, 
as  in  any  ordinary  section;  (2)  any  necessary  abdominal  work 
is  completed;  (3)  the  broad  ligament  of  one  side  is  held  tense, 
through  a  bloodless  space  under  the  ovarian  ligament  a  long 
hemostat  is  passed,  and  the  round  ligament  caught  about 
three  inches  from  the  cornu  and  pulled  through  the  broad 
ligament;  (4)  the  opposite  side  is  secured  in  the  same  way; 
(5)  the  loops  are  sewed  to  each  other  in  the  middle  line, 
and  to  the  uterine  body.  They  are  spread  out  rather  widely 
and  secured  with  Pagenstecher  thread  near  the  fundus.  If 
they  are  sewed  low  down  on  the  uterus,  the  organ  may  fall 
backward  over  them;  (6)  the  abdomen  is  closed  as  usual. 

VI.  The  Gilliam  operation,  in  which  the  round  ligaments 
are  pulled  through  the  peritoneum  and  muscle,  under  the 
fascia,  at  either  side  of  the  lower  end  of  the  median  abdominal 
incision,  and  sewed  together  in  the  midline  and  also  where 
they  emerge  from  the  muscle.  The  Mayo  modification  of  this 
tunnels  under  the  fascia  and  catches  the  ligaments  where  they 
enter  the  internal  ring  and  pulls  them  over  to  the  middle  line. 

Advantages. — -(i)  Withstands  subsequent  childbirth  fairly 
well;    (2)  ovaries  are  suspended. 

Disadvantages. — -(i)  Owing  to  variation  in  the  point  of 
attachment  of  the  round  ligaments,  the  uterus  is  often  not 
far  enough  forward,  but  points  toward  the  umbilicus;  (2) 
some  danger  of  intestinal  obstruction;  (3)  some  danger  of 
sloughing  of  the  ligament,  which  is  obviated  if  the  ligament  is 
not  bruised  in  handling  and  the  opening  in  the  muscle  is  large 
enough  not  to  constrict  it. 

Indications. — ^Any  case  where  by  removal  of  the  tubes,  the 
uterine  attachments  of  the  round  ligaments  are  not  interfered 
with. 

Technic. — (i)  The  abdomen  is  opened  in  the  ordinary  way, 
by  median  incision;  (2)  any  necessary  intra-abdominal  work 
is  completed;  (3)  on  each  side  of  the  wound,  at  its  lower  angle, 
a  forceps  is  thrust  through  the  muscle  and  peritoneum,  the 
round  ligament  grasped  midway  in  its  course  through  the  broad 


124 


THE    UTERUS 


ligament,  and  pulled  through  the  opening  made  by  the  forceps ; 
(4)  the  peritoneum  is  closed;  (5)  the  loops  of  ligaments  are 
sewed  together  in  the  middle  line  and  also  to  the  muscle, 
where  they  emerge,  using  number  i  chromic  catgut;  (6)  the 
fascia,  fat  and  skin  are  closed  in  the  usual  way. 

VII.  Cofey  operation,  a  modification  of  the  old  Mann  opera- 
tion. The  round  ligaments  are  folded  down  the  anterior 
face  of  the  uterus  as  far  as  the  peritoneal  reduplication,  and 
then  back  again  to  the  cornu,  and  secured  by  suture. 

Advantages. — None,    over    the     above-described     methods. 

Disadvantages. — The  same  that  caused  the  discarding  of  the 
Mann  and  similar  operations:   (i)   Depends  upon  the    thin 


Fig.   53. — The  Coffey  operation  for  retroversion,  seen  from  in  front. 
{After  Cross  en.) 

pubic  end  of  the  round  ligament;  (2)  extensive  adhesions 
from  the  suturing;  (3)  does  not  withstand  subsequent  child- 
birth; (4)  high  proportion  of  failures. 

Technic. — (i)  Ordinary  abdominal  incision  and  completion 
of  intra-abdominal  work;  (2)  the  round  ligament  is  carried 
down  to  the  peritoneal  reduplication  on  the  anterior  face  of 
the  uterus  and  held  there  by  a  stitch.  It  is  then  carried  back 
to  the  cornu  and  held  by  another  one;  (3)  the  two  layers  of 
the  ligament  are  sewed  to  the  anterior  face  of  the  uterus,  using 
number  i  chromic  catgut;  (4)  a  fold  of  peritoneum  from  the 
broad  ligament  is  then  sewed  over  the  reduplicated  round 
ligaments;  (5)  the  abdomen  is  closed  in  the  usual  way. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS         1 25 

VIII.  Vaginal  fixation  of  the  uterus  is  never  justifiable  in 
women  of  childbearing  age.  It  always  causes  severe  dystocia. 
In  women  past  the  menopause,  the  most  satisfactory  technic 
is  the  Watkins-Wertheim  interposition  operation,  as  used 
in  the  cure  of  cystocele,  but  unless  the  patient  has  had  children, 
the  vaginal  operation  is  better  not  attempted. 

III.  Cancer  of  the  Fundus  or  Body  of  the  Uterus 

Cancer  of  the  fundus  or  body  of  the  uterus  is  seen  usually 
at  a  later  age  than  cancer  of  the  cervix,  forty-five  to  sixty 
being  the  usual.  It  is  much  less  frequent  than  cancer  of  the 
cervix — about  one-eighth.  It  is  also  more  common  in  nullip- 
arous  women,  just  the  reverse  of  cervical  cancer. 

Its  progress  is  slow,  it  is  slow  to  give  metastases,  and  there- 
fore is  surgically  more  favorable  than  cervical  cancer.  Metas- 
tases take  place  into  the  deep  sacral  lumbar  or  renal  glands, 
but  may  go  into  the  groin  along  the  lymphatics  of  the  round 
ligament. 

Symptoms. — (i)  In  over  80  per  cent,  of  cases,  the  first 
symptoms  appear  after  the  menopause;  (2)  the  first  symptom 
is  a  watery,  seropurulent  uterine  discharge,  without  odor  and 
rather  scanty;  (3)  then  irregular  bleeding,  not  profuse,  but 
persistent;  (4)  a  foul  blood-streaked  discharge,  in  the  intervals 
of  bleeding,  as  the  growth  begins  to  slough;  (5)  pain  of  an 
intense  burning  kind — a  late  and  usually  unfavorable  symptom. 

When  the  disease  begins  during  menstrual  life,  it  is  often 
mistaken  for  profuse  menstruation  as  an  indication  of  the 
impending  menopause — a  most  dangerous  fallacy.  Any  ir- 
regular persistent  bleeding  in  a  woman  past  forty  demands 
immediate  investigation  as  to  its  cause. 

Cancer  of  the  body  of  the  uterus  is  frequently  found  associ- 
ated with  fibroid  tumor.  If  in  a  case  of  bleeding  myoma, 
radical  operation  is  for  any  reason  deferred,  a  dilatation  and 
curettage  should  always  be  done,  to  exclude  cancer,  especially 
if  :i;-ray  treatment  or  radium  is  to  be  begun.  The  rays  often 
stimulate  active  growth  of  the  malignant  process. 


126  •  THE    UTERUS 

Diagnosis. — (i)  Bimanual  examination  of  the  uterus  reveals 
practically  nothing  abnormal;  at  the  most  a  uterus  slightly 
enlarged;  (2)  specular  examination  shows  a  normal  or  slightly 
eroded  cervix;  (3)  exploratory  dilatation  and  curettage  with 
microscopic  examination  of  the  scrapings  is  the  only  means  of 
diagnosis,  and  should  promptly  be  done. 

Kinds  of  Cancer. — (i)  Adenocarcinoma — much  the  common- 
est; (2)  malignant  adenoma;  (3)  chorionepithelioma.  Squa- 
mous-celled  epithelioma  does  not  occur  in  the  body  of  the 
uterus. 

Treatment. — Abdominal  panhysterectomy  (Wertheim)  is 
much  the  best.  The  technic  is  precisely  that  described  under 
cancer  of  the  cervix,  with  the  following  exceptions:  (i)  The 
uterine  cavity  is  injected  with  strong  (40  per  cent.)  formalin 
solution,  to  sterilize  it;  (2)  the  cervix  is  sewed  up,  to  prevent 
leakage;  (3)  curetment  and  cauterization  of  the  crevix  are 
of  course  omitted. 

Prognosis.- — Favorable — about  75  per  cent,  should  be  per- 
manently cured.  The  presence  of  adhesions  is  of  great  prog- 
nostic value,  recurrence  being  much  more  likely  if  they  are 
present.  The  operation  is  much  easier  than  that  for  cancer 
of  the  cervix,  and  the  primary  mortality  is  low.  When  recur- 
rence does  take  place  it  is  as  a  retroperitoneal  growth  or  as 
general  abdominal  carcinomatosis.  Both  are  inoperable,  and 
even  palliative  treatment  by  a-ray  or  radium  offers  little  hope. 

Chorion  epithelioma  (Deciduoma  Malignum,  Syncytial 
Cancer)  is  a  most  malignant  growth,  following  labor,  abortion 
or  frequently  hydatid  mole.  About  one-half  of  the  reported 
cases  of  chorion  epithelioma  have  been  preceded  by  hyatid 
mole.  It  arises  from  malignant  proliferation  of  the  syn- 
cytium, and  gives  most  rapid  metastases  all  over  the  body, 
but  particularly  to  the  lungs,  vagina  and  brain.  The  nodules 
are  soft,  spongy,  purplish  in  color.  Microscopically  they  con- 
sist mainly  of  masses  of  syncytial  cells  and  large  blood  spaces. 
It  may  occur  coincident  with  pregnancy  or  hydatid  mole, 
or  at  any  interval  up  to  several  years  thereafter. 


ABNORMy^LITIES    AND    DISEASES    OF    THE    UTERUS         1 27 

Symptoms  are  usually  irregular  bleeding  from  the  uterus 
occurring  after  the  puerperium  is  completed,  accompanied 
by  a  foul-smelling  discharge.  In  many  cases  the  appearance 
of  metastases  in  the  vagina  is  the  first  symptom  detected. 
The  uterus  is  large  and  soft  and  the  os  patulous.  The  diagno- 
sis rests  upon  the  microscopic  examination  of  a  portion  of  the 
tissue. 

Treatment. — Abdominal  panhysterectomy  as  soon  as  the 
diagnosis  is  made. 

Prognosis. — If  detected  early  and  promptly  treated  by 
panhysterectomy,  recurrence  is  unlikely.  If  seen  in  the  stage 
when  vaginal  or  other  metastases  have  appeared,  the  outcome 
is  dubious.  Operation  is  always  advisable,  however,  as 
metastases  have  been  reported  to  disappear.  The  growth  may 
occasionally  be  extruded  like  a  miscarriage,  and  spontaneous 
cure  result.  It  is  usually  the  most  rapidly  growing  and  spread- 
ing of  all  the  malignant  tumors. 

IV,  Endometritis 

Endometritis  is  the  commonest  disease  of  women.  By 
itself  it  is  rare,  but  it  is  associated,  in  a  chronic  hyperplastic 
glandular  form,  with  most  of  the  abnormalities  of  the  pelvic 
organs. 

Kinds.  — (i)  Acute;  (2)  chronic — the  usual  form.  The 
causes  of  acute  endometritis  are  (a)  sepsis;  (b)  gonorrhea; 
(c)  rarely  infectious  diseases  like  diphtheria,  typhoid,  etc. 
The  causes  of  chronic  are:  (i)  Chronic  hyperplasia  of  the 
glands,  secondary  to  chronic  congestion  of  the  uterus  from 
any  cause;  (2)  persistent  after  the  acute  form,  as  in  gonorrhea; 
(3)  tubercular — secondary  to  tuberculosis  of  the  tubes;  (4) 
syphilitic. 

The  types  of  chronic  endometritis  are  (i)  Chronic  hyper- 
plastic glandular — where  the  glands  are  enormously  increased 
in  number  (much  the  commonest) ;  (2)  chronic  interstitial — 
where  the  stroma  is  hypertrophied  without  corresponding 
increase  of  the  glands;  (3)  chronic  atrophic,  where  the  glands 


128  THE    UTERUS 

have  disappeared  and  the  stroma  is  represented  by  a  thin 
fibrous  band. 

Causes. — (i)  Acute  septic,  due  to  infection  after  labor, 
miscarriage  or  dirty  instruments  used  in  treatment;  (2) 
acute  gonorrheal,  due  to  gonococcus;  (3)  acute  infectious, 
due  to  intense  hyperemia,  caused  by  bacterial  invasion;  (4) 
tubercular  is  secondary  to  tuberculosis  of  the  tubes;  (5) 
chronic  hyperplastic  glandular  and  chronic  interstitial  are 
secondary  to  any  pelvic  condition  causing  chronic  congestion 
of  the  uterus.  These  causes  are  so  numerous,  that^chronic 
hyperplastic  endometritis  is  the  commonest  disease  of  women; 
(6)  atrophic  is  physiologic  after  the  menopause  and  rarely 
seen  at  other  times,  except  over  the  dome  of  a  submucous 
fibroid. 

Symptoms. — -(i)  Leukorrheal  discharge,  varying  in  kind  and 
amount,  depending  on  the  cause.  In  sepsis  it  is  seropurulent, 
bloody  and  usually  foul.  In  gonorrhea  profuse,  yellow  and 
irritating.  In  chronic  endometritis  it  is  milky;  (2)  erosion 
of  the  cervix;  (3)  usually  menorrhagia,  with  increased  fre- 
quency of  menstruation.  In  acute  infectious  fevers,  uterine 
bleeding  justifies  a  diagnosis  of  acute  endometritis;  (5)  rarely 
pain,  except  midway  between  the  periods  (Mittelschmerz). 
The  cause  of  this  pain  is  unknown. 

Treatment. — Depends  upon  the  cause.  The  acute  septic 
form  requires:  (i)  Rest  in  bed;  (2)  four  hot  vaginal  douches  a 
day;  (3)  ice-bag  constantly  to  lower  abdomen;  (4)  if  after 
abortion  or  labor,  a  daily  intra-uterine  douche  of  tincture  of 
iodin  3  drams,  alcohol  (95  per  cent.)  8  ounces,  sterile  water 
q.s.ad.  four  pints;  (5)  no  curettage. 

The  acute  gonorrheal  form  is  described  in  the  chapter  on 
Gonorrhea.     (Chapter  XVI). 

Tuberculosis  of  the  endometrium  requires  abdominal  pan- 
hysterectomy, provided  other  important  organs  are  not  in- 
volved, and  all  apparent  evidence  of  the  disease  can  be  removed 
with  the  uterus  tubes  and  ovaries. 

The  treatment  of  chronic  hyperplastic  glandular  endome- 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  1 29 

tritis  is:  (i)  The  correction  of  its  cause  (retroversion,  lacerated 
cervix  or  any  other  cause  of  chronic  uterine  congestion). 
Unless  this  is  done,  no  permanent  cure  is  possible. 

Local  treatment  is  (i)  Palliative  or  (2)  Radical. 

Palliative  treatment  consists  in  (i)  hot  vaginal  douching, 
twice  daily;  (2)  boroglycerid  tampons  (both  these  of  temporary 
benefit  only) ;  (3)  instillations  into  the  uterine  cavity  of  argyrol 
25  per  cent.,  silvol  10  per  cent,  or  nitrate  of  silver  i  per  cent.; 
(4)  in  cases  accompanied  by  bleeding,  pituitrin  }/2  cc.  hypo- 
dermically  twice  daily  for  10  doses. 

Radical  treatment  consists  of  dilatation  of  the  cervix  and 
curettage  of  the  uterine  cavity.  This  is  permissible  only  in 
chronic  cases  (except  those  of  gonorrheal  origin)  and  never  in 
acute  ones.  The  danger  in  acute  or  chronic  gonorrheal  cases 
is  the  prompt  development  of  pyosalpinx. 

Technic. — (i)  The  patient  is  prepared  as  for  any  plastic 
operation,  and  arranged  in  the  dorsal  position  on  a  table 
(not  bed).     Anesthesia  is  necessary. 

2.  The  anterior  lip  of  the  cervix  is  caught  by  a  double 
tenaculum,  and  the  cervix  pulled  down  by  an  assistant. 

3.  A  light  Goodell  dilator  is  inserted  in  the  cervical  canal 
and  the  blades  separated  to  one  inch  on  the  scale. 

4.  A  heavy  Wa,then  dilator  is  inserted  and  the  blades  slowly 
separated,  by  the  screw  in  the  handle  and  not  by  manual 
pressure,  until  a  transverse  dilatation  of  one  inch  is  secured. 

5.  With  a  sharp  Sims  curet,  used  with  only  the  grasp  of 
the  thumb,  and  two  fingers,  the  uterine  cavity  is  firmly 
and  systematically  curetted.  The  order  is  first  the  anterior 
wall,  then  the  right  lateral,  posterior,  left  lateral  and  the 
fundus  in  the  order  named.  As  the  soft  velvety  endome- 
trium is  curetted  off,  the  curet  grates  on  the  harder  muscle, 
this  feel  should  be  uniform  all  over  the  cavity  before  the 
curettage  is  discontinued. 

6.  A  Martin  spoon  curet  is  used  to  curet  out  the  angles  of 
each  cornu,  as  the  Sims  is  too  broad  to  enter  them. 

7.  The  uterine  cavity  is  explored,  for  possible  polyps,  with 


130  THE    UTERUS 

the  Emmett  curetment  forceps.  This  is  very  important  in 
cases  where  hemorrhage  is  a  symptom.  The  curei  will  sUp 
over  surprisingly  large  polyps,  without  removing  them. 

8.  The  uterus  is  washed  out  through  a  two-way  Bozeman 
catheter,  ^^ith  sterile  water. 

9.  No  packing  is  necessary,  unless  there  is  profuse  bleeding, 
which  is  very  rare. 

10.  The  patient  is  kept  in  bed  for  seven  days  after  the 
operation. 

11.  All  scrapings  should  be  examined  microscopically. 
Appearance  of  Curetted  Material. — Some  idea  of  the  probable 

result  of  the  microscopic  examination  is  gained  by  the  appear- 
ance of  the  curetted  material. 

(i)  Normal  endometrium  is  soft  thick,  dark  red,  infiltrated 
with  blood;  (2)  hypertrophied  endomeirium  is  the  same,  with 
numerous  whitish  granules  like  sago ;  (3)  chorion  is  white  and 
shaggy,  when  floated  out  in  water ;  (4)  decidua  reflexa  is  dark 
on  one  side,  gray  and  shaggy  on  the  other;  (5)  old  blood-clots 
are  jet  black;  (6)  cancer  is  Uke  brain  tissue;  (7)  chorion  epithe- 
lioma is  dark  purple  and  solid  like  a  blood  clot. 

Regeneration  of  the  endometrium  after  curettage  takes  place 
from  the  deep  utricular  glands  in  about  five  days.  Too 
vigorous  use  of  the  curet  may  result  in  obliteration  of  the  uterine 
cavity. 

Perforation  of  the  uterus  during  curettage  is  recognized  by 
the  sudden  slipping  in  of  the  curet,  far  beyond  the  normal 
length  of  the  uterus.  In  a  clean  case,  the  accident  is  not  a 
serious  one.  All  further  manipulations  should  stop  at  once, 
and  above  all,  the  uterus  should  not  be  washed  out.  The 
patient  should  be  put  to  bed  and  let  alone.  Abdominal  section 
is  unnecessary. 

In  a  septic  case:  (i)  Cease  all  further  intra-uterine  manipula- 
tions; (2)  open  the  posterior  vaginal  vault;  (3)  pack  Douglas 
pouch  with  gauze;  (4)  return  to  bed,  in  Fowler  position; 
(5)  continuous  enteroclysis,  40  drops  to  minute.  After 
forty-eight  hours  the  gauze  packing  is  removed  and  replaced 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS         131 

by  a  T  drainage  tube.     Abdominal  section  is  rarely  needed, 
and  then  only  if  there  are  signs  of  peritonitis. 

V.  Fibroid  Tumors  of  the  Uterus  (Myoma  Uteri;  Fibromyoma 
Uteri;  Leiomyoma  Uteri) 

These  are  composed  of  fibrous  and  muscular  tissue  (the 
more  fibrous  tissue  the  harder  the  tumor)  and  develop  in  the 
wall  of  the  uterus. 

Frequency. — At  least  50  per  cent,  of  women  have  some 
degree  of  fibroid  tumor.  Most  of  them  remain  insignificant, 
cause  no  symptoms  and  require  no  treatment.  A  fibroid 
is  rare  in  a  woman  under  twenty-five  years  of  age,  and  most 
tumors  begin  their  growth  between  the  ages  of  twenty-five  and 
forty.  New  tumors  rarely  develop  after  the  menopause,  and 
rapid  growth  of  a  tumor  at  this  time  nearly  always  means 
sarcoma. 

Cause  is  unknown;  heredity  plays  some  part;  they  are  very 
common  in  single  women  past  forty;  and  their  frequency  in 
negroes  suggests  a  racial  cause.  As  they  develop  only  during 
menstrual  life,  the  function  of  menstruation  is  a  definite 
factor,  and  women  who  have  not  borne  children  are  more  likely 
to  develop  fibroids. 

Site  of  development  is  chiefly  in  the  wall  of  the  uterus, 
above  the  internal  os.     Cervical  fibroids  are  rare. 

Kinds. — (i)  Interstitial  (intramural),  when  the  fibroid  is  in 
the  uterine  wall;  (2)  subserous,  when  it  has  grown  outward, 
toward  the  peritoneum;  (3)  submucous  when  it  bulges  into 
the  uterine  cavity;  (4)  intraligamentary,  when  it  has  grown 
into  the  layers  of  the  broad  ligament. 

Bleeding  is  most  profuse  in  submucous  growths;  least  so  in 
subserous;  pain  is  most  common  in  submucous  (explusive)  or 
in  intraligamentary  (pressure  on  sacral  plexus) . 

A  subserous  myoma  may  grow  outward,  until  it  is  attached 
to  the  uterus  only  by  a  pedicle.  If  this  pedicle  becomes 
twisted,  it  may  slough  through  and  the  fibroid  become  para- 
sitic, getting  a  meager  blood  supply  from  adherent  omentum. 


132 


THE   UTERUS 


A  submucous  myoma  may  grow  so  far  in  the  uterine  cavity 
as  to  develop  a  pedicle  and  become  a  fibroid  polyp.  Due  to 
efforts  of  the  uterus  to  expel  it,  the  pedicle  is  often  so  lengthened 
as  to  allow  the  polyp  to  hang  outside  the  cervix. 

General  Life  History. — Fibroids  are  of  slow  growth,  usually 
moderate  size,  have  a  capsule,  do  not  infiltrate  the  surrounding 
muscle,  have  poor  blood  supply  and  are  nearly  always  multiple. 
The  only  fibroid  which  cannot  be  shelled  from  its  capsule 
is  the  rare  adenomyoma. 


Suhperitoneal 


interstitial- 


'uhmueous 


Pig.    54. — Showing  varieties  of  uterine  fibroma.      {After  Stewart.) 


Degenerations. — (i)  Edematous  (cystic)  due  to  passive 
congestion;  (2)  hyaline  (unimportant,  seen  in  portions  of  all 
fibroids);  (3)  myxomatous  (really  cystic  edema);  (4)  throm- 
bosis and  red  degeneration  (seen  in  fibroids  in  pregnancy) 
dangerous  because  of  infection;  (5)  necrosis — usually  second- 
ary to  thrombosis  in  pregnancy;  (6)  fatty — most  common  in 
pregnancy,  but  also  seen  postmenopause;  (7)  calcification, 
usually  postmenopause;  (8)  malignant — nearly  always  sar- 
coma. Carcinoma  is  possible  by  (a)  invasion  from  the 
endometrium,  or  {h)  carcinomatous  degeneration  of  included 
glands,   but  is   very  rare.     Pregnancy  usually  causes  rapid 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS 


133 


Pig.  55. — a.  Multiple,  subperitoneal  fibroids  of  the  uterus;  b,  large 
single  interstitial  myoma  (fibroid)  in  the  anterior  uterine  wall.  This  is 
the  type  that  simulates  pregnancy.      (After  Graves.) 


Fig.  56. —  Moderate  sized  submucous  fibroid.  These  growths  cause  the 
most  bleeding,  and  are  prone  to  become  necrotic  from  reduction  of  their 
blood  supply.     {After  Graves.) 


134  'i'HE    UTERUS 

growth  in  fibroids,  due  to  the  increase  in  blood  supply.  Mter 
delivery,  the  fibroid  may  shrink. 

After  the  menopause,  tliere  is  commonly  a  considerable 
reduction  in  size,  but  the  presence  of  the  tumor,  especially  if 
submucous,  delays  the  appearance  of  the  menopause  for  five 
to  fifteen  years.  Adenocarcinoma  of  the  endometrium, 
associated  with  fibroid  tumor  is  not  uncommon,  especially 
after  the  menopause.  This  is  entirely  distinct  from  any  de- 
generation of  the  fibroid  itself. 

Sjrmptoms. — Many  fibroids  present  no  symptoms  whatever, 
even  though  of  large  size.  The  symptoms  depend  to  a  large 
extent  upon  the  situation  of  the  tumor. 

(i)  Bleeding. — This  is  at  first  menorrhagia,  due  to  a  dia- 
•pedesis  through  the  vessels.  The  periods  are  at  first  length- 
ened, increased  in  amount  with  many  clots,  and  later  may  be 
almost  continuous.  A  secondary  anemia  always  results, 
hemoglobin  being  as  low  as  25-30  per  cent.  A  large  subserous 
growth  may  cause  no  abnormal  bleeding.  Bleeding  from  a 
fibroid  is  always  venous  and  therefore  serious  only  by  its 
long  continuance. 

(2)  Pain — which  is  either  expulsive  (in  submucous  growths) 
or  pressure,  in  subserous  and  intraligamentary.  In  the  latter, 
sciatic  neuralgia  is  common.  In  pregnancy,  pain  is  often 
diffused  over  the  whole  tumor  and  is  severe. 

(3)  Presence  of  the  tumor,  which  when  it  reaches  sufficient 
size,  gives  a  bold  outline  to  the  abdominal  enlargement,  with 
sharp  rise  and  fall.  The  tumor  is  usually  irregular,  nodular 
and  very  hard  and  firm.  Large  single  submucous  or 
intramural  tumors  give  an  outline  startlingly  like  that  of  a 
pregnant  uterus. 

Secondary  symptoms  are:  (i)  Anemia;  (2)  hyperthyroidism; 
(3)  very  irritable  nervous  system;  (4)  heart  lesion  (compensatory 
dilatation,  "myoma  heart").  All  these  tend  to  return  to  nor- 
mal after  the  removal  of  the  tumor. 

Diabetes  is  very  common  with  fibroids. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  135 

A  foul  vaginal  discharge  usually  means  a  necrotic  gangren- 
ous fibroid  polyp  and  not  malignancy. 

Leukorrhea  is  common,  being  a  thin  serous  discharge  from 
the  atrophied  endometrium  over  the  dome  of  a  submucous 
fibroid,  mixed  with  a  thicker  mucoid  discharge  from  the  hyper- 
trophied  glands  around  its  base. 

Effect  of  Fibroids  on  Pregnancy. — To  some  extent  they  pre- 
vent conception,  about  30  per  cent,  of  women  with  myoma 
being  sterile.     This  is  more  than  double  the  normal  percentage. 

Diagnosis  is  usually  easy.  Bimanual  examination  shows  the 
hard,  irregular  nodular  uterus,  though  there  are  many  chances 
of  mistake,  such  as:  (i)  A  pelvic  abscess  or  pyosalpinx  adherent 
in  Douglas'  pouch — not  a  serious  mistake  as  abdominal  section 
is  indicated  in  either;  (2)  a  very  tense  ovarian  cyst  pushing  the 
uterus  far  forward;  (3)  adenocarcinoma  of  the  body  of  the 
uterus,  causing  moderate  symmetrical  enlargement.  Only  to 
be  diagnosed  by  exploratory  curettage;  (4)  a  large  symmetrical 
intramural  or  submucous  fibroid  may  simulate  most  closely 
a  pregnant  uterus.  Successive  examinations,  a  week  apart, 
will  clear  up  the  diagnosis.  The  most  valuable  single  sign  is 
the  consistency  of  the  cervix,  which  shows  none  of  the  soften- 
ing characteristic  of  pregnancy. 

TREATMENT 

Treatment  is  either  (i)  palliative  or  (2)  radical.  Palliative 
treatment  consists  in  (i)  styptics;  (2)  dilatation  and  curetment; 
(3)  electricity;  (4)  ovarian  or  mammary  extract;  (5)  radiation 
— x-TSiy  or  radium. 

Palliative  Treatment.^ — Indications:  (i)  Small  tumors, 
presenting  as  their  only  symptom  moderate  menorrhagia, 
with  no  suspicion  of  malignant  degeneration;  (2)  tumors  which 
are  stationary  in  size  or  growing  very  slowly;  (3)  tumors 
which  give  no  pressure  symptoms;  (4)  women  near  the  meno- 
pause, remembering  always  that  the  menopause  may  be 
delayed  for  five  to  fifteen  years. 

(i)  Styptics  are  usually  of  little  value  and  then  only  when 


136  THE    UTERUS 

the  bleeding  is  a  moderate  menorrhagia.  Pituitrin  Y2  mil 
twice  daily  for  two  days  before  and  the  first  two  days  of  the 
period;  hydrastinin  gr.  ^i,  by  mouth  four  times  daily  during 
the  period;  ergotin  gr.  i  (or  i  ampule  aseptic  ergot)  hypodermic- 
ally  twice  daily  for  the  first  three  days  of  the  period;  a  pill 
of  ergotin  gr.  i,  hydrastinin  gr.  ^"2,  stypticin  gv.  3^-2  (exceedingly 
expensive)  four  times  daily  for  two  days  before  and  the  first 
two  days  of  the  period  are  the  most  reliable,  but  not  much  is 
to  be  expected  of  them. 

(2)  Dilatation  and  curettage,  in  the  hope  of  controlling  the 
bleeding  temporarily  by  removal  of  the  h3^ertrophied  en- 
dometrium or  possibly  a  polyp,  is  often  of  value.  It  will  be 
possible  only  if  the  uterine  cavity  is  not  distorted  by  nodular 
growths,  hence  it  should  not  be  attempted  unless  the  uterus 
is  fairly  symmetrical  in  outline. 

(3)  Electricity — intra-uterine  application  of  galvanic  current, 
positive  pole  to  the  uterine  sound,  using  a  current  of  forty  to 
sixty  milliamperes  for  fifteen  minutes  three  times  a  week  for 
a  series  of  thirty  treatments,  is  of  moderate  value.  It  is 
contraindicated  in  tumors  with  severe  bleeding,  degeneration 
or  in  the  presence  of  pelvic  inflammation. 

(4)  Ovarian  extract  (gr.  5  four  times  daily  by  mouth); 
Mammary  extract  (gr.  5  four  times  daily  by  mouth) ;  adrenalin 
ITLx  of  Mo 0  0  solution  hypodermically  or  by  mouth  four  times 
daily  are  all  of  practically  no  value,  and  while  recommended 
from  time  to  time  by  different  authors,  are  not  v/orth  a 
trial. 

(5)  Radiation — either  x-ray  or  radium — is  the  most  valuable 
and  powerful  of  all  palliative  agents,  in  spite  of  certain  dis- 
advantages. In  young  women  there  is  danger  of  a  permanent 
menopause,  with  both  x-ray  and  radium.  Neither  have  any 
efifect  upon  the  development  of  subsequent  degeneration,  and 
in  cases  of  early  and  possibly  unsuspected  malignancy,  may 
stimulate  it  to  the  utmost  activity. 

X-ray  is  attended  with  considerable  danger  of  severe  skin 
burns  and  the  risk  of  burning  is  considerably  increased  in 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  137 

severe  anemia  and,  above  all,  syphilis.  Often  severe  nervous 
disturbances  follow  its  use. 

With  radium  the  danger  of  genital  fistula  is  present,  as  the 
radium  tube  is  inserted  in  the  cervix  and  uterine  canal. 
Radiation  is  not  advisable  in  bleeding  fibroids,  after  the  meno- 
pause, as  this  symptom  always  means  degeneration.  Neither 
method  is  at  all  safe  unless  used  by  an  expert,  and  the  expense 
of  radium  removes  it  from  the  armamentarium  of  the  general 
practitioner. 

In  spite  of  the  dangers,  radium  remains  the  most  efficient 
means  of  checking  the  bleeding  of  fibroids,  and  is  the  only 
method  to  be  considered  in  those  patients  constitutionally 
unfit  for  surgical  relief. 

Radical  treatment  comprises  (I)  vaginal  hysterectomy,  (II) 
abdominal  supravaginal  hysterectomy;  (III)  abdominal 
myomectomy;  (IV)  vaginal  myomectomy;  (V)  Battey's 
operation;  (VI)  ligation  of  the  uterine  arteries. 

Indications. — (i)  Large  tumors  with  marked  symptoms; 
(2)  severe  pain;  (3)  severe  bleeding;  (4)  rapid  growth  —nearly 
always  indicating  sarcoma;  (5)  omophobia — the  mental  state 
of  the  woman  who  dwells  upon  the  presence  of  the  tumor  and 
becomes  practically  mentally  unbalanced  upon  this  one  point. 

I.  Vaginal  hysterectomy  has  no  advantage  over  abdominal 
hysterectomy,  and  is  in  most  cases  very  much  inferior  to  it. 
It  must  never  be  attempted  if  the  bulk  of  the  tumor  is  such 
that  it  cannot  be  delivered  easily  through  the  opening  of  the 
anterior  vaginal  vault.  Its  field  is  in  fat  women,  in  whom 
an  abdominal  section  would  be  a  formidable  undertaking,  or  in 
women  who,  because  of  heart  lesion,  would  not  stand  the 
Trendelenburg  position  usually  required  in  abdominal  hysterec- 
tomy. The  best  technic  is  supravaginal,  extraperitoneal  hys- 
terectomy, but  the  uterus  must  be  free  from  adhesion,  whichever 
technic  is  chosen. 

Technic. — (i)  The  patient  is  prepared  for  both  abdominal 
and  vaginal  operation;  (2)  she  is  arranged  in  the  dorsal  posi- 
tion under  anesthesia;  (3)   the  anterior  and  posterior  lips  of 


138  THE    UTERUS 

the  cervix  are  caught  with  double  tenacula  and  pulled  down, 

(4)  the  anterior  vaginal  wall  is  incised  longitudinally  from 
the  urethra  to  the  cervix,  and  transversely  across  the  cervix; 

(5)  the  flaps  of  anterior  vaginal  mucosa  are  dissected  free 
from  the  bladder  and  the  uterovesical  hgament  cut;  (6)  the 
bladder  is  pushed  up,  until  the  peritoneal  reduplication  is 
visible.  This  is  opened  and  the  uterine  body  pulled  out  through 
the  opening  with  double  tenacula.  The  presence  of  adhesions 
makes  this  step  difhcult,  if  not  impossible;  (7)  the  peritoneum 
of  the  prevesical  space  is  sewed  to  the  uterine  body,  as  low 
as  possible  on  the  posterior  wall.  This  shuts  off  the  peri- 
toneal cavity  and  the  rest  of  the  operation  is  extraperitoneal ; 
'(8)  the  ovarian  artery  is  tied,  the  stump  clamped  in  a  hemo- 
stat  and  cut  away.  The  round  ligament  is  tied  and  cut, 
and  these  procedures  repeated  on  the  opposite  side;  (9)  the 
uterine  arteries  are  tied  and  cut,  and  the  cervix  ampu- 
tated by  a  V-shaped  excision,  just  above  where  the  peritoneum 
has  been  attached  posteriorly;  (10)  the  cervical  stump  is  closed 
by  interrupted  suture,  and  the  vaginal  wound  sutured. 

II.  Abdominal  supravaginal  hysterectomy  (in  which  a  stump 
of  cervix  is  left)  is  the  operation  of  choice  in  the  majority  of 
cases.  It  is  much  easier  and  quicker  than  panhysterectomy. 
The  only  advantage  of  the  latter  is  that  it  prevents  subsequent 
development  of  cancer  in  the  cervical  stump,  an  occurrence  so 
rare  as  to  be  negligible. 

Supravaginal  hysterectomy  is  indicated  in  (i)  Women  near 
the  menopause;  (2)  very  large  tumors;  (3)  nodular  tumors,  in 
which  the  uterus  iz  hopelessly  involved;  (4)  degenerations; 
(5)  pelvic  inflammation. 

Technic. — (i)  The  patient  is  prepared  as  for  any  abdominal 
section,  and  anesthetized. 

2.  The  abdomen  is  opened,  in  the  midline,  by  an  incision 
long  enough  to  permit  delivery  of  the  tumor. 

3.  The  edges  of  the  incision  are  held  apart  by  a  self-retaining 
retractor. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS 


139 


4.  The  uterus  is  grasped  with  a  heavy  volsellum,  is  dehvered 
through  the  wound  and  held  far  forward  over  the  symphysis. 

5.  The  intestines  are  packed  back  by  pads,  so  that  none  of 
them  are  visible,  and  Douglas'  pouch  is  shut  off  by  the  pads. 

6.  The  ovarian  artery  of  each  side  is  clamped,  the  round 
ligaments  also,  and  a  clamp  placed  above  these,  to  control 
reflux  bleeding. 


Pig.  57. — Left  ovarian  vessels  tied,  vesical  peritoneum  divided  and 
pushed  down,  and  left  uterine  vessels  ligated.  Cervix  amputated  and 
uterus  pulled  up  and  out,  exposing  right  uterine  artery,  which  is  clamped 
an  inch  above  the  cervical  stump.  The  two  following  steps  are  clamping 
the  right  round  ligament  and  right  ovarian  vessels,  when  the  mass  is 
removed.     (Kelly.) 


7.  The  broad  ligaments  are  cut  between  the  hemostatic  and 
reflux  clamps,  as  far  as  the  uterine  artery. 

8.  The  anterior  peritoneal  reduplication  is  cut,  straight 
across,  to  connect  the  two  incisions  already  made,  and  the 
bladder  pushed  down. 


I40  THE    UTERUS 

9.  The  posterior  peritoneum  is  cut  across,  at  the  level  of  the 
attachments  of  the  uterosacral  ligaments. 

10.  The  uterine  arteries  are  clamped  and  cut  and  the  cervix 
amputated  by  a  V-shaped  exsection. 

11.  The  cervical  canal  is  sterilized  by  the  actual  cautery. 

12.  The  cervical  stump  is  closed  at  once  by  interrupted 
suture  of  number  3  chromic  catgut,  taking  the  muscle  but 
not  the  peritoneum. 

13.  The  ovarian,  round  ligaments  and  uterine  arteries  are 
tied,  across  the  pelvis  in  regular  order,  using  number  3  chromic 
catgut. 


Pig.   50. — The  stump  of  the  cervix  and  broad  ligaments,  after  completion 
of  supravaginal  hysterectomy. 

14.  The  two  layers  of  peritoneum  are  closed  across  the 
pelvis,  by  a  continuous  number  3  chromic  catgut  stitch,  and 
the  abdomen  closed  as  usual. 

15.  It  is  doubtful  whether  leaving  one  or  both  ovaries,  to 
prevent  the  surgical  menopause,  is  worth  while.  Many  of 
these  cases  require  subsequent  operation  for  cystic  ovaries. 
The  disagreeable  symptoms  of  the  menopause  can  be  controlled 
better  by  hypodermic  injections  of  corpus  luteum  extract. 

Surgical  Menopause.— In  nearly  all  cases  where  the  uterus, 
tubes  and  ovaries  have  been  removed,  prior  to  the  natural  meno- 
pause, the  disagreeable  symptoms  of  the  surgical  menopause 
(flashes  of  heat,  tremors,  nervousness,  headache,  etc.)  can  be 
relieved  entirely  by  hypodermic  intramuscular  administra- 
tion of  either  corpus  luteum  extract  or  whole  ovarian  extract, 
beginning  on  the  fourth  day  after  operation.     The  injections 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS 


141 


are  made  deep  in  the  deltoids,  alternately,  giving  i  mil  a  day 
(representing  each  40  grains  of  the  dried  substance)  for  twenty- 
four  doses,  and  repeating  in  series  of  twelve  doses  as  the  effects 
(which  are  cumulative)  wear  off.  Usually  forty-eight  doses 
in  all  are  required.  Several  weeks  separate  the  series  of  doses. 
The  younger  the  patient,  the  more  doses  are  needed. 

III.  Abdominal  myomectomy  is  indicated  when  the  tumor  is 
single  or,  if  multiple,  can  be  shelled  out  without  extensive 
mutilation   of    the    uterus.     It   is 
absolutely  contraindicated  in   (i)  y''*     ""^^ 

women  near  the  menopause;  (2) 
degenerations;  (3)  pelvic  inflam- 
mation. 

Technic. — (i)  The  technic  is  the 
same  as  supravaginal  hysterec- 
tomy, until  the  uterus  is  delivered 
from  the  wound. 

2.  The  uterine  wall  is  incised 
over  the  growth,  until  the  capsule 
is  opened,  and  the  tumor  is  shelled 
out  with  the  finger  or  spatula. 
The  bleeding  is  negligible  and  no 
ligatures  are  required,  as  a  rule. 

3.  The  bed  of  the  tumor  is  ob- 
literated by  interrupted  sutures  of 
number  3  chromic  catgut,  not  in- 
volving the  peritoneum. 

4.  The  excess  of  capsule,  uterine  muscle  and  peritoneum  is 
trimmed  off,  to  secure  an  accurate  fit  in  closing  the  wound. 

5.  The  peritoneal  coat  is  closed  by  continuous  number  3 
catgut  suture. 

6.  Several  separate  growths  may  thus  be  enucleated. 

.  7.  When  all  are  removed  the  abdomen  is  closed  in  the  usual 
way. 

Advantages. — (i)  Leaves  the  uterus  and  does  not  establish 
the  menopause. 


CX 


Fig.  S9.-Pointsof  en- 
trance of  the  needle  in  infil- 
tration of  the  cervix  in  local 
anesthesia  by  novocain  or 
other  solutions,  preliminary  to 
anterior  vaginal  hysterotomy. 
a.  The  cervix;  b,  anterior  in- 
filtration under  the  bladder; 
c,  c,  lateral  infiltration;  d,  d, 
infiltration  of  the  cervical 
muscle,  parallel  to  the  cervical 
canal;  e,  posterior  infiltration. 
The  crosses  are  the  points  of 
insertion  of  the  needle. 


142  THE    UTERUS 

Disadvantages. — (i)  Danger  of  infection,  especially  if,  during 
the  enucleation  of  the  tumor,  the  uterine  cavity  has  been 
opened.  (2)  Other  tumors,  unnoticed  during  the  operation, 
may  develop  later  and  require  removal.  (3)  Danger  of  in- 
testinal adhesions  to  the  uterine  wounds  (4)  Weakens  the 
uterine  wall,  in  case  of  subsequent  pregnancy.  (5)  The  scar 
tissue,  in  extensive  resections,  may  cause  pernicious  vomiting 
in  subsequent  pregnancies. 

The  operation  is  advisable  in  young  women  who  wish,  if 
possible,  to  bear  children,  and  in  women  who  for  sentimental 
reasons. prefer  it  to  removal  of  the  uterus.  In  other  cases,  the 
disadvantages  should  be  fully  weighed  before  performing  it. 

rV.  Vaginal  myomectomy  is  indicated  in  intra-uterine 
growths  (polyps)  even  of  considerable  size,  or  in  necrotic 
fibroid  polyps. 

Technic: — (i)  The  patient  is  prepared  for  both  plastic  and 
section,  (the  latter  in  case  it  proves  impossible  to  remove  the 
tumor  by  the  vaginal  route);  She  is  arranged  in  the  dorsal 
position  under  anesthesia. 

2.  The  anterior  lip  of  the  cervix  is  caught  with  a  double 
tenaculum  and  the  canal  dilated.  Unless  the  growth  is  small, 
dilatation  of  the  cervix  does  not  give  sufficient  room.  In 
many  cases,  the  anterior  vaginal  wall  must  be  separated  from 
the  bladder,  the  bladder  pushed  up  and  the  cervix  cut  in 
the  middle  line,  through  the  internal  os  (anterior  vaginal 
hysterotomy). 

3.  The  growth  is  caught  with  a  volsellum,  and  if  it  has  a 
pedicle,  it  is  twisted  off  and  removed. 

4.  If  the  attachments  are  firm  (as  they  usually  are)  the 
capsule  is  incised  near  the  base,  with  scissors,  and  the  growth 
enucleated  with  the  finger,  strong  traction  downward  being 
made  on  the  volsellum  holding  it. 

5.  If  the  growth  is  of  large  size,  it  is  necessary  to  remove  it 
piecemeal,  cutting  off  piece  after  "piece  with  heavy  scissors 
{morcellation) . 

6.  The   hysterotomy   wound  in  the  cervix  is  repaired  with 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS         1 43 

interrupted  sutures  of  number  3  chromic  catgut,  and  the  vaginal 
walls  sewed  back  in  place. 

7.  The.  uterine  cavity  is  washed  out,  and  the  vagina  packed 
with  sterile  gauze,  which  is  removed  in  twenty-four  hours. 
Uterine  packing  is  rarely  needed,  and  only  if  there  is  persistent 
bleeding. 

V.  Battey's  operation — double  oophorectomy  to  secure  shrink- 
age of  the  fibroid  by  establishing  the  surgical  menopause 
— is  an  illogical  procedure  now  rarely  used. 

VI.  Ligation  of  the  uterine  arteries,  to  starve  the  tumor 
by  shutting  off  the  major  portion  of  its  blood  supply,  has  been 
extensively  recommended,  but  is  now  obsolete. 

Fibroids  in  pregnancy  are  often  stimulated  to  excessive 
growth.  They  should  be  let  alone,  unless  they  cause  severe 
pain,  severe  bleeding  or  grow  alarmingly.  Myomectomy  is 
to  be  preferred  to  hysterectomy,  to  allow,  if  possible,  the 
continuance  of  pregnancy. 

RECURRENT  FIBROIDS 

Recurrent  fibroids,  so  called,  after  supravaginal  hysterec- 
tomy, are  sarcomata,  and  are  inoperable.  They  should  be 
treated  by  massive  doses  of  radium,  in  repeated  short  exposures, 
but  the  prognosis  is  bad. 

ADENOMYOMATA 

Adenomyomata  are  a  special  type  of  fibroid.  They  grow 
diffuse  in  the  uterine  wall,  contain  glands  identical  with  those 
of  the  endometrium  (from  which  they  are  derived)  and  em- 
bedded in  endometrial  stroma.  They  develop  mostly  in  the 
posterior  uterine  wall,  near  the  fundus.  They  are  usually 
small,  and  do  not  as  a  rule  produce  serious  symptoms. 

Symptoms. — (i)  Menorrhagia;  (2)  menstrual  pain;  (3) 
moderate  asymmetrical  enlargement  of  the  uterus. 

Treatment — A"-ray,  radium  or  hysterectomy,  if  the  symp- 
toms are  sufficiently  severe. 


144  THE    UTERUS 

These  tumors  are  prone  to  malignant  degeneration,  which  is 
carcinoma  from  the  enclosed  glands. 

VI.  Hysteralgia 

Hysteralgia  or  excessive  pain  referred  to  the  uterus,  without 
demonstrable  cause,  is  usually  rheumatic.  It  is  sometimes  so 
severe  as  to  simulate  peritonitis,  though  the  absence  of  fever, 
rapid  pulse  and  high  leukocyte  count  will  differentiate  it. 

The  treatment  is  aspirin  gr.  lo  four  times  daily,  which  will 
promptly  relieve  the  pain.  A  single  dose  of  morphin  sulphate 
gr.  y^i  hypodermically  at  the  onset  is  justifiable,  but  should 
not  be  repeated. 

VII.  Infantile  Uterus 

Infantile  uterus  is  of  two  types:  (i)  Dwarf  uterus,  where  the 
uterus  is  much  below  the  normal  size,  but  perfectly  propor- 
tioned; (2)  disproportion  of  cervix  to  body,  so  that  the  cervix 
is  much  longer  than  the  body,  though  both  are  below  normal. 
This  is  much  the  commoner  form. 

Causes. — (i)_  Congenital,  (2)  superinvolution  after  child- 
birth; (3)  repeated  curettage  of  the  uterus  (really  another 
cause  of  superinvolution). 

S3nnptoms. — (i)  Scanty  menstruation,  often  with  long 
intermissions  between  the  periods;  (2)  dysmenorrhea;  (3) 
sterility. 

Treatment. — (i)  Dilatation  of  the  cervix,  without  curettage, 
to  relieve  dysmenorrhea;  (2)  hypodermic  injections  intra- 
muscularly of  I  mil  corpus  luteum  extract,  daily  doses  in 
series  of  twelve  doses,  with  two  weeks'  intermission  between 
series;  (3)  electrical  stimulation,  with  negative  pole  to  uterine 
sound,  using  galvanic,  slow  faradic  and  sinusoidal  current 
for  fifteen  minutes  each  (total  forty-five  minutes  for  each 
treatment)  every  other  day  for  six  to  eight  weeks.  Much 
better  results  can  be  hoped  for  in  acquired  infantilism  (super- 
involution)  than  in  the  congenital  form. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS         145 

Vni.  Inversion  of  the  Uterus 

Inversion  of  the  uterus  is  one  of  the  rarest  of  diseases 
of  women,  and  nearly  always  occurs  as  a  complication  of 
childbirth. 

Kinds. — (i)  Acute — due  to  traction  of  the  placenta  after 
dehvery;   (2)  chronic  due  to  prolonged    traction  of    tumors; 

(3)  incomplete,  where  the  fundus  does  not   pass  the   cervix, 

(4)  complete,  when  the  fundus  is  in  the  vagina. 

Causes. — (i)  Traction  of  the  placenta — either  spontaneous 
or  due  to  manual  efforts  at  extraction — after  labor.  (2) 
Prolonged  traction  of  fibroid  polyp. 

Symptoms. — In  the  acwte  variety  (i)  shock;  (2)  hemorrhage; 
(3)  fundus  felt  in  the  vagina;  (4)  abdominal  palpation  shows 
a  deep  cleft  across  what  remains  of  the  uterine  body.  This 
variety  requires  immediate  manual  reposition,  and  its  symp- 
toms are  so  alarming  that  it  can  hardly  be  overlooked  or 
neglected.  Occasionally  it  does  persist,  however,  and  becomes 
chronic. 

Symptoms  of  Chronic  Inversion. — (i)  Bleeding — irregular  and 
profuse;  (2)  considerable  leukorrheal discharge, often  offensive; 
(3)  bimanual  examination  shows  a  tumor  in  the  upper  vagina, 
surrounded  by  a  collar  of  healthy  cervix;  (4)  also  that  the 
uterine  body  cannot  be  felt,  but  if  the  deep  pressure  above  the 
symphysis  is  made,  a  deep  cleft  extending  across  what  remains 
of  the  corpus  uteri;  (5)  a  uterine  sound  will  show  that  there 
remains  no  uterine  cavity. 

Differential  diagnosis  is  from  myomatous  polyp.  This 
forms  a  polypoid  mass,  surrounded  by  a  collar  of  healthy 
cervix,  and  causes  bleeding  and  discharge,  but  here  the  resem- 
blance ceases.  The  uterine  body  is  plainly  felt,  there  is  no 
depression  across  it,  the  uterine  cavity  is  not  obliterated  and 
is  always  longer  than  normal. 

Complications. — (i)  Contraction  of  the  cervix  (always  pres- 
ent in  the  chronic  variety,  and  occurring  in  the  acute  after  a 


146 


THE    UTERUS 


few  hours),     (2)    Gangrene   of   the   corpus  uteri,   where   the 

cervical  contraction  is  tight  enough  to  cut  off  circulation. 

Treatment  (of  the  chronic  variety) . — (i)  Attempt  to  reduce 

the  inversion  by  taxis,  like  a  hernia,  will  almost  certainly  fail. 

(2)  Long-continued  pressure,  by  gauze  packing,  renewed 
every  twenty-four  hours;  a  ball  and  stem  pessary,  supported 
by  a  belt  and  perineal  straps.  Both  have  been  occasionally 
successful,  but  there  is  considerable  danger  of  sepsis. 

(3)  Operative  treatment,  by  far  the  simplest,  safest  and 
quickest. 


Pig.  60. — Diagram  to  illustrate  the  differential  diagnosis  between  inver- 
sion of  the  uterus  and  a  fibro-adenomatous  polyp  protruding  from  the 
cervix. 


Methods. — (i)  With  the  patient  in  the  dorsal  position,  anes- 
thetized, the  cervix  is  held  wth  tenacula,  and  cut  posteriorly 
in  the  midline,  far  enough  to  relieve  constriction.  The 
uterine  body  is  replaced  and  the  cervical  cut  repaired.  This 
will  succeed  in  the  vast  majority  of  cases. 

(2)  Spinelli  Operation. — The  bladder  is  separated  from  the 
cervix,  as  in  anterior  vaginal  hysterotomy.  The  uterus  is 
spHt  in  half,  along  its  anterior  border,  as  far  as  the  fundus. 
It  is  re-inverted,  and  the  uterine  and  vaginal  wounds  closed. 
This  is  merely  an  extension  of  the  first  operation,  is  much 
more  formidable  and  usually  unnecessary. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS         147 

(3)  Abdominal  section  for  the  relief  of  inversion  is  never 
necessary. 

(4)  If  the  fundus  is  gangrenous,  vaginal  hysterectomy  should 

be  performed. 

IX.  Metritis 

Acute  metritis  is  exceedingly  rare,  outside  the  puerperium. 
It  is  due  to  bacterial  invasion,  usually  streptococcic.  The 
moderate  inflammatory  and  circulatory  changes  occurring 
as  a  result  of  prolonged  congestion  from  any  cause  is  usually 
called  chronic  metritis,  though  it  is  not,  strictly  speaking, 
inflammatory.  As  a  result,  there  is  a  fibrous  change  in  the 
myometrium,  the  muscle  becoming  almost  like  cartilage. 
True  bacterial  invasion  may  occur,  independent  of  the  puer- 
perium, from  (i)  gonorrhea;  (2)  tuberculosis;  (3)  dirty 
instruments  used  in  treatment. 

Symptoms  of  the  acute  form  are  those  of  acute  sepsis,  and 
treated  by  rest  in  bed,  ice  bag  to  the  lower  abdomen,  hot 
vaginal  douches  and  stimulation. 

Symptoms  of  the  chronic  form  are:  (i)  Backache;  (2) 
bearing-down  pain  in  pelvis;  (3)  bleeding — at  first  menorrhagic 
and  later  continuous  and  profuse;  (4)  leukorrhea;  (5)  blood- 
tinged  mucous  discharge  midway  between  periods,  with  con- 
siderable pain;  (6)  as  this  form  of  metritis  is  often  seen  in 
syphilis,  a  Wassermann  test  should  always  be  made. 

Bimanual  examination  shows  a  large,  heavy  and  very  firm 
uterus. 

Treatment. — (i)  Correction  of  any  cause  of  chronic  con- 
gestion of  the  uterus  which  may  be  found;  (injuries  of  child- 
birth being  the  most  common);  (2)  styptics  such  as  ergo  tin 
gr.  I  four  times  daily,  hydrastinin  gr.  i  four  times  daily, 
pituitrin  one-half  mil  hypodermically  twice  daily  for  ten 
doses;  (3)  dilatation  and  curettage  to  remove  hypertrophied 
and  angiomatous  endometrium;  (4)  radium,  in  massive  doses 
with  short  exposure;  (5)  .T-ray —  with  due  regard  to  the  danger 
of  burning;  (6)  salvarsah,  if  due  to  syphihs;  (7)  abdominal 
hysterectomy,  if  all  other  means  have  failed. 


148  '  THE    UTERUS 

X.  Polyps 

Polyps  are  of  two  kinds:  (i)  Small  mucous  polyps  of  the 
endometrium;  (2)  fibromyomatous  polyps,  sessile  or  peduncu- 
lated, varying  in  size  from  a  cherry  to  the  fetal  head.  The 
latter  are  submucous  myomata  which  have  grown  doT\Ti  into 
the  uterine  cavity.  Uterine  polyps  are  much  less  common 
than  cervical  ones. 

Symptoms. — (i)  Menorrhagia,  becoming  metrorrhagia;  (2) 
moderate  leukorrheal  discharge;  (3)  often  expulsive  pain,  from 
the  uterus  trying  to  expel  a  myomatous  polyp,  as  a  foreign 
body;  (4)  mucous  polyps  cause  no  enlargement  of  the  uterus; 
fibromatous  often  cause  a  very  considerable  increase  in  size. 

Treatment. — Dilatation  and  curettage,  followed  by 
exploration  of  the  uterine  cavity  with  placental  forceps.  This 
is  most  essential,  as  the  curet  will  slip  over  poh'ps  that  the 
placental  forceps  will  grasp  and  extract.  If  a  pedunculated 
myomatous  polyp  is  found,  it  can  be  twisted  off  and  removed. 
A  sessile  polyp,  mth  a  broad  attachment,  requires  anterior 
vaginal  hysterotomy  (to  secure  sufficient  dilatation)  and 
enucleation  after  its  base  has  been  incised  with  scissors.  A 
polyp  too  large  to  be  removed  whole  must  be  cut  in  pieces 
.(morcellation).  In  every  case,  both  polyp  and  endometrial 
scrapings  must  be  examined  microscopically,  for  carcinoma. 
As  polyps  are  often  multiple,  the  operator  must  search  the 
uterine  cavity  thoroughly  and  not  be  satisfied  that  with  the 
finding  of  a  single  pohqD  his  operation  is  complete. 

Degenerations. — (i)  Necrosis  and  sepsis.  These  are  most 
common  in  elderly  women,  who  are  bad  surgical  risks.  The 
tumors  are  so  soft  and  friable  that,  if  they  can  be  easily  reached, 
they  can  be  removed  with  the  forceps,  without  anesthesia. 
(2)  Malignant  degeneration,  diagnosed  only  by  the  microscope, 
is  an  absolute  indication  for  panhysterectomy. 

XL  Prolapse  of  the  Uterus 

Prolapse  of  the  uterus  is,  in  the  vast  majority  of  cases,  a 
consequence  of  childbirth,  and  will  be  discussed  in  its  proper 
place  in  Chapter  Xlll. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS  1 49 

Prolapse  is  possible  in  nulliparous  women,  independent  of 
childbirth,  from  the  following  causes: 

I.  Congenital  (rare,  but  the  most  hkely  cause  in  young  girls). 
(2)  Excessive  muscular  effort.  (3)  Rupture  of  an  ovarian 
multilocular  cyst,  with  the  weight  of  the  extruded  fluid  causing 
total  prolapse  of  the  uterus  and  inversion  of  the  vagina.  (4) 
Ascites,  having  the  same  effect.  (5)  In  elderly  women,  due 
to-  increased  intra-abdominal  pressure  and  relaxed  tissues, 
post-menopause. 

Congenital  prolapse  in  young  girls  is  usually  only  apparent, 
being  due  to  a  great  supra-  and  infravaginal  hypertrophy  of 
the  cervix,  the  uterine  body  remaining  at  or  near  its  proper 
level.  These  cases  are  relieved  by  amputation  of  the  cervix. 
The  other  cases  are  usually  true  prolapse,  of  which  the  palha- 
tive  and  curative  treatment  is  identical  with  that  for  cases 
due  to  childbirth,  described  in  Chapter  XIII. 

XII.  Sarcoma  of  the  Uterus 

Sarcoma  of  the  uterus  is  forty  times  less  frequent  than 
carcinoma. 

Point  of  origin  is  either  (i)  the  connective  tissue  of  the  endo- 
metrium; (2)  connective  tissue  of  the  myometrium.  That  from 
the  endometrium  is  very  rare;  that  from  the  myometrium  is 
almost  invariably  a  degeneration  of  a  fibromyoma  and  is 
called  myosarcoma. 

Sarcoma  of  the  endometrium  is  usually  polypoid,  most 
commonly  in  the  cervical  canal  and  hangs  from  the  cervix  like 
a  bunch  of  purple  grapes — hydatidiform  sarcoma  of  the  cervical 
canal.  Rarely  sarcoma  of  the  endometrium  is  diffuse,  and 
invades  the  uterine  wall  as  does  carcinoma.  Sarcomatous 
degeneration  of  a  fibroid  usually  starts  in  the  center  of  the 
growth  and  spreads  rapidly.     On  section  it  appears  gelatinous. 

Age  of  occurrence  is  usually  thirty  to  fifty,  the  disease  being 
very  rare  either  side  of  these  limits. 

Histology. — (i)  Mixed-cell  sarcoma  is  the  commonest;  (2) 
spindle  cell  next  in  frequency;  (3)  sarcoma  of  the  endometrium 


150  '  THE   UTERUS 

is  usually  round-cell;  (4)  very  rarely  it  is  melanotic;  (5)  also 
very  rarely,  carcinoma  and  sarcoma  are  found  in  the  same 
uterus. 

Symptoms. — (i) Bleeding;  (2)  foul  discharge;  (3)  pain; 
essentially  the  same  as  carcinoma.  Hydatidiforrn  sarcoma  of 
the  cervix  is  recognized  at  a  glance,  though  a  piece  must  be  ex- 
cised and  examined  microscopically.  Sarcoma  of  the  endo- 
metrium of  the  corpus  uteri  can  be  diagnosed  only  by  curettage 
and  microscopic  examination.  Sudden  growth  in  a  fibroid, 
particularly  with  ascites,  usually  means  sarcomatous  degen- 
eration and  is  an  indication  for  immediate  panhysterectomy. 
About  3  to  5  per  cent,  of  fibroids  undergo  sarcomatous  change. 

Persistent  bleeding  from  the  vagina  in  children,  before 
puberty,  if  precocious  menstruation  be  eliminated,  is  most 
often  due  to  cervical  sarcoma. 

Metastasis  is  much  more  common  and  occurs  earlier  than  in 
carcinoma,  hence  the  operative  results  are  less  favorable. 
Diffuse  sarcoma  gives  metastasis  earliest,  next  is  the  polypoid 
type,  and  latest  is  sarcoma  of  a  fibroid.  Metastasis  occurs 
to  distant  portions  of  the  body,  is  very  common  retroperito- 
neally,  and  often  appears  as  a  general  sarcomatosis. 

Treatment. — Abdominal  section,  with  panhysterectomy  if 
possible,  as  soon  as  the  diagnosis  is  made.  Palliative  treatment 
is  unsatisfactory,  neither  x-ray  nor  radium  having  much,  if  any, 
effect.  In  degenerated  myomata,  .T-ray  and  radium  are 
positively  contraindicated,  as  they  stimulate  the  malignant 
process  to  new  activity. 

Prognosis  is  best  in  degenerated  fibroids,  recurrence  being 
about  50  per  cent.  In  other  types,  recurrence  is  almost 
invariable,  either  locally  or  by  distant  metastasis. 

XIII.  Subinvolution  of  the  Uterus 

Subinvolution  of  the  uterus  is  the  failure  of  the  uterus  to 
regain  its  normal  size  after  childbirth  or  miscarriage.  The 
condition  is  always  secondary  to  a  primary  cause,  and  is  due  to 
congestion  or  failure  of  firm  contraction. 


ABNORMALITIES    AND    DISEASES    OF    THE    UTERUS         151 

Causesr— (i)  Retained  portion  of  the  ovum;  (2)  lacerations; 
(3)  displacement  of  the  uterus;  (4)  hyper trophied  decidua; 
(5)  puerperal  sepsis;  (6)  peri-uterine  adhesions. 

Symptoms. — (i)  Bearing  down  and  backache;  (2)  headache 
(vertical  or  occipital);  (3)  leukorrhea;  (4)  metrorrhagia; 
(5)  bladder  irritabihty. 

Diagnosis  is  easily  made  by  bimanual  examination,  the 
uterus  being  larger  and  less  firm  than  normal. 

Treatment  is  the  removal  of  the  cause.  If  this  is  done,  the 
uterus  rapidly  regains  its  normal  size,  without  further  treat- 
ment. The  process  can  be  hastened  by  (i)  hot  vaginal  douches, 
three  times  daily;  (2)  tincture  of  digitahs  TUv  t.  i.  d.;  (3) 
hypodermic  of  pituitrin  3^^  mil  twice  daily  for  six  doses; 
though  these  measures  are  unnecessary. 

[XIV.   SUPERINVOLUTION  OF  THE  UTERUS 

Superinvolution  of  the  uterus  is  an  exaggerated  reduction 
in  size  of  the  uterus.     It  is  much  rarer  than  subinvolution. 

Causes. — (i)  Hyperlactation ;  (2)  pelvic  inflammation;  (3) 
hemorrhage;  (4)  rapidly  repeated  pregnancies;  (5)  repeated 
curetment  of  the  uterus,  at  short  intervals. 

There  is  a  moderate  form,  common  during  lactation  or  after 
miscarriage,  occasionally  going  to  extreme  diminution  in  size, 
called  lactation  atrophy.  The  uterine  walls  are  thin  and 
easily  perforated,  a  fact  to  be  remembered  in  curetments 
on  nursing  mothers  or  after  miscarriage. 

Diagnosis. — Bimanual  examination  shows  a  uterus  much 
reduced  in  size,  sometimes  so  small  as  scarcely  to  be  felt. 

Treatment^— Spontaneous  return  to  normal  or  near  normal 
size,  is  the  rule,  if  the  cause  be  found  and  removed.  In  cases 
without  obvious  cause:  (i)  Electrical  stimulation  of  the  uterus, 
negative  pole  to  uterine  sound;  galvanic,  slow  faradic  and 
sinusoidal  currents  each  fifteen  minutes  (total  forty-five 
minutes  for  each  treatment)  three  times  weekly;  (2)  hypo- 
dermic extract  of  corpus  luteum  i  mil  (representing  40  grains 


152  •         THE   UTERUS 

of  the  dried  substance)  daily  in  series  of  12  doses;  (3)  hypo- 
dermics of  whole  ovarian  extract,  in  the  same  dosage.  Rarely 
the  condition  resists  all  treatment  and  is  permanent. 

XV.  Tuberculosis  of  the  Uterus 

Tuberculosis  of  the  uterus  is  usually  confined  to  the  endo- 
metrium, and  is  nearly  always  secondary  to  tuberculosis  of  the 
tubes.  It  is  found  in  patches  in  the  endometrium  and  only 
rarely  invades  the  muscle. 

Sjrmptoms. — (i)  Persistent  leukorrhea;  (2)  rarely  bleeding; 
(3)  occasionally  long-continued  amenorrhea. 

Diagnosis. — By  bimanual  examination  the  uterus  is  slightly 
enlarged,  fixed  and  the  salpingitis  associated  with  it  can 
be  felt.  Exploratory  curettage  and  examination  of  the  scrap- 
ings is  useful  as  a  diagnostic  measure,  but  is  never  curative, 
as  the  disease  is  secondary  to  the  tubes. 

Treatment  is  abdominal  section,  with  double  salpingectomy, 
and  also  hysterectomy,  if  curettage  has  shown  the  endometrium 
to  be  extensively  involved. 

Prognosis,  in  the  absence  of  extensive  active  foci  elsewhere 
in  the  body,  is  good.  If  these  foci  are  present,  any  operation 
for  tuberculosis  of  the  uterus  is  not  worth  while. 


CHAPTER  Vlll 
DISEASES  OF  THE  FALLOPIAN  TUBES 

I.  NORMAL  ANATOMY  AND  RELATIONS  OF  THE  FALLOPIAN 

TUBES 

The  Fallopian  tubes  run  from  each  cornu  of  the  uterus, 
through  the  upper  layer  of  the  broad  hgaments,  to  the  ovaries, 
with  which  the  lower  fimbriae  of  the  tube  are    usually   in 


\ 


Fig.   6i. — Section  of  the  normal  Fallopian  tube  near  the  uterine  cornu. 

{Beyea.) 

contact.    They  are  about  12  cm.  long,  the  left  being  slightly 
the  longer 

Structure. — The  tubal  walls  consist  of  a  mucous,  muscular 
and  serous  coat.    The  mucosa  is  in  longitudinal  folds,  simple 

153 


154 


DISEASES    OF    THE    FALLOPIAN    TUBES 


and  slightly  elevated  in  the  inner  portion;  exceedingly  com- 
plicated and  well  marked  in  the  outer  third  and  the  ampulla. 
There  are  no  glands  and  no  submucosa;  the  cells  are  columnar 
and  ciliated,  the  cilia  lashing  toward  the  uterus. 


Fig.  62. — Section  of  the  normal  Fallopian  tube  near  the  abdominal  ostium. 

(Beyea.) 

The  muscular  coat  is  in  three  layers:  (i)  An  inner  longitudinal 
(not  well  marked);  (2)  a  middle  circular  and  (3)  an  outer 
longitudinal. 

The  serous  coat  is  in  three  closely  knit  layers,  and  is  best 
marked  in  the  inner  two-thirds  of  the  tube. 


CONGESTION  OF  THE  FALLOPIAN  TUBES  I55 

The  caliber  of  the  tubes,  is,  at  the  uterine  end,  that  of  a 
bristle  of  an  average  hairbrush.  It  increases  steadily  toward 
the  fimbriated  extremity,  where  it  is  the  size  of  a  goose  quill 
(.8  cm.). 

Divisions. — (i)  Uterine  mouth  (funnel-shaped)  in  each 
cornu;  (2)  interstitial  portion  (that  running  through  the 
uterine  wall);  (3)  isthmus  (the  narrow  portion  of  the  inner 
one-half);  (4)  the  tube  proper;  (5)  the  infundibulum  (the 
expanded  outer  third  of  the  tube) ;  (6)  the  fimbrice  (folds  of 
mucosa  at  the  abdominal  end). 

The  portion  of  the  broad  ligament  through  which  the  tube 
runs  is  called  the  mesosalpinx. 

Arteries  are  four  or  five  small  branches  from  the  utero- 
ovarian  anastomosis. 

Veins  accompany  the  arteries;  they  terminate  in  the  ovarian 
and  uterine  veins.  The  left  side  is  more  subject  to  engorge- 
ment because  the  left  ovarian  vein  empties  into  the  left  renal 
vein  at  a  right  angle  and  has  no  valve,  while  the  right  ovarian 
vein  empties  into  the  inferior  vena  cava  and  has  a  well-marked 
valve.  For  this  reason,  which  favors  congestion,  and  because 
the  rectum  dips  down  behind  the  broad  ligament  on  the  left 
side,  pain  from  inflammatory  reaction  is  usually  more  marked 
on  the  left  than  on  the  right  side. 

Lymphatics  empty  into  the  deep  lumbar  glands. 

Nerves  come  from  the  uterovaginal  and  ovarian  plexus. 
There  is  a  well-marked  tubal  plexus  in  the  subserosa. 

Hydatid  of  Morgagni  is  a  small  cyst,  representing  the  ter- 
minal end  of  the  Miillerian  duct,  hanging  from  the  ovarian 
fimbria  by  a  long  slender  pedicle.  It  has  a  connective  tissue 
wall,  is  lined  with  pavement  epithelium,  and  contains  a  clear 
serum.    Its  maximum  size  is  that  of  a  hazelnut, 

II.  CONGESTION  OF  THE  FALLOPIAN  TUBES 

Congestion  of  the  tubes  without  inflammation,  is  always 
secondary  to  some  interference  of  the  circulation,  most  com- 


156  DISEASES    OF    THE    FALLOPIAN    TLBES 

monly  from  retroversion  of  the  uterus.  There  are  no  symptoms 
by  which  the  condition  can  be  diagnosed;  it  is  seen  at  opera- 
tion, when  the  tubes  are  inspected.  The  tubes  are  dark  red 
or  purple,  swollen,  and  usually  blood  can  be  expressed  from 
the  lumen.  The  canal  is  not  obstructed,  and  it  is  not  neces- 
sary to  remove  them.  The  congestion  disappears  when  the 
cause  is  removed. 

In  intrahgamentary  ovarian  cyst  the  tube  is  stretched  over 
the  top  of  the  cyst,  congested  and  enormously  elongated  (one 
case  thirty  inches  long). 

III.  EXTRA -UTERINE  PREGNANCY  (ECTOPIC  GESTATION; 
TUBAL  GESTATION) 

Extra-uterine  pregnancy  may  occur  at  any  point  from  the 
peritoneal  cavity  (primary  abdominal  pregnancy)  to  the  intra- 
mural portion  of  the  tube  (cornual  pregnancy).  It  is  most 
common  in  the  outer  one-third  of  the  tube. 

Causes. — (i)  Some  interference  with  normal  progress  of 
the  ovum  through  the  tube,  most  likety  adhesions  from  a 
previous  salpingitis,  or  from  destruction  of  the  cilia  of  the 
epithelium.  (2)  Lodging  of  the  ovum  in  a  diverticulum  of  the 
tube  (rare).  (3)  Unusually  long  and  convoluted  tubes.  (4) 
External  transmigration  of  the  ovum  (from  the  right  ovary  to- 
the  left  tube  or  vice  versa). 

In  the  last  two,  the  length  of  the  journey  is  such  that  before 
it  is  finished  the  ovum  is  too  large  to  progress  further. 

Classification. — (i)  Tubal  (much  the  commonest);  (2) 
ovarian;  (3)  abdominal;  and  (4)  combinations  of  the  above, 
such  as  tubo-uterine  (cornual);  tubo-ovarian,  etc. 

Primary  abdominal  pregnancy  is  where  the  fertilized  ovum 
lodges  in  the  peritoneal  cavity;  secondary  abdominal  pregnaticy 
is  one  which  began  in  the  tube,  escaped  through  the  fimbriated 
extremity  into  the  peritoneum,  and  there  continued  its  career. 

Frequency  is  said  to  be  one  in  five  hundred  cases,  and  most 
often  between  the  ages  of  twenty  and  thirty  years.  Tubal 
pregnancy  is  by  far  the  commonest.     Ovarian  pregnancy  is 


EXTRA-UTERINE    PREGNANCY 


157 


exceedingly  rare.  Primary  abdominal  pregnancy  is  also 
very  rare  but  secondary  abdominal  pregnancy,  where  the 
embryo  was  originally  in  the  tube,  but  escaped  into  the 
abdominal  cavity  and  there  continued  its  development  for 
some  time  is  not  very  uncommon.  In  such  a  case  a  child 
may  die  at  the  time  of  its  extrusion  into  the  abdominal  cavity, 
and  be  retained  as  a  lithopedion  for  an  indefinite  time  (fifty- 
six  years  in  one  case) ,  or  it  may  partially  absorb  and  the  bones 
ulcerate  through  into  the  bowel  or  bladder;  or  it  may  continue 


Pig.  63.  The  possible  sites  of  extra-uterine  pregnancy:  i,  Cornual  or 
interstitial;  2,  tubal  in  the  isthmus;  3,  tubal;  4  and  5,  ampullar.  Ovarian 
and  primary  abdominal  pregnancy  are  exceedingly  rare.      {Gilliam.) 


its  development  until  term,  or  past  it,  and  be  delivered  alive 
by  abdominal  section. 

Development.^ — In  the  tube  the  ovum  behaves  much  as  it 
does  in  the  uterus.  It  burrows  into  the  mucosa;  this  is  im- 
perfectly transformed  into  decidua  and  the  chorion  and  am- 
nion develop  as  in  normal  pregnancy.  Decidua  is  also  formed 
in  the  uterine  cavity,  but  is  not  as  thick  as  in  normal  pregnancy. 
This  decidua  after  the  death  or  removal  of  the  embryo  is  cast 
off,  but  sometimes  must  be  removed  by  curetment. 

Terminations.^ — Most  commonly  tiihal  abortion,  or  extrusion 
of  the  ovum  through  the  dilated  fimbriated  extremity  of  the 


158 


DISEASES    OF    THE    FALLOPIAN    TL^E 


tube,  with  more  or  less  severe  hemorrhage,  at  about  the  sixth 
to  tenth  week  of  pregnancy.  Next  in  frequency,  erosion 
of  the  tubal  wall  (the  so-called  rupture)  with  severe  internal 
hemorrhage;  erosion  of  the  tube  with  hemorrhage  into  the 
layers  of  the  broad  ligament;  the  conversion  of  the  fetus  into  a 
lithopedion  or  calcification  of  the  fetus;  rarely  death  of  the 
embryo  and  complete  resolution. (?)     A  tubo-uterine  or  inter- 


FiG.  64. — The  site  of  the  hematocele  in  extra-uterine  pregnancy,  felt  as  an 
exceedingly  tender  mass  in  Douglas'  pouch.      {After  Crossen.) 

stitial  pregnancy  may  make  its  way  into  the  uterine  cavity 
and  progress  normally  to  term  and  very  rarely  a  tubal  preg- 
nancy may  develop  to  term.  Tubal  pregnancy  not  infre- 
quently occurs  twice  in  the  same  individual.  Rarely  combined 
extra-uterine  and  intra-uterine  pregnancy  have  been  found. 
Pelvic  hematocele  is  the  collection  of  blood  in  Douglas' 
pouch,  palpable  by  vaginal  examination.  It  is  soft  and 
doughy,  and  may  reach  a  very  considerable  size,  being  often 
palpable  by  abdominal  examination,  and  extending  as  high  as 
the   umbihcus.     When   the   tube   ruptures,   or   the   ovum   is 


EXTRA-UTERINE   PREGNANCY  I59 

extruded  through  the  fimbriated  extremity,  the  embryo  is 
usually  rapidly  absorbed,  and  no  trace  of  it  is  found  in  the 
mass  of  blood-clots  forming  the  pelvic  hematocele. 

The  uterine  bleeding  associated  with  ectopic  pregnancy  is 
venous  in  origin,  comes  from  the  endometrium  and  is  never 
by  reflux  from  the  tube. 

Clinical  History  and  Symptoms.^ — The  patient  has  usually 
had  children  before,  but  the  last  some  years  previously.  She 
misses  one  or  two  periods,  which  then  return  as  irregular 
bleeding.  At  the  same  time  occurs  violent  stabbing  pain  in 
the  lower  abdomen,  severe  enough  to  make  her  faint,  and  when 
she  recovers  consciousness,  she  is  nauseated.  The  pain  recurs 
in  paroxysms,  increasing  in  frequency  and  severity,  but  the 
interval  between  thdm  is  free  from  pain.  Finally  after  one 
of  these  attacks  of  pain,  the  symptoms  of  internal  hemorrhage 
appear.  Frequently,  however,  this  entire  history  may  be 
negative,  and  the  first  symptom  is  a  violent  attack  of  pain  with 
the  signs  of  internal  hemorrhage.  There  is  often  a  discharge  of 
decidua  from  the  uterus,  described  by  the  patient  as  "a  piece 
of  flesh,  different  from  a  blood-clot,"  but  no  ovum  is  dis- 
charged, except  in  the  rare  instances  when  there  is  a  combined 
intra-uterine  and  extra-uterine  pregnancy.  There  is  a  slight 
elevation  of  temperature,  averaging  99.5°F.  and  a  leukocytosis 
of  12,000-14,000. 

On  vaginal  examination  the  patient  presents  confirmatory 
signs  of  pregnancy,  the  uterus  not-  so  large  as  one  would  expect 
to  find  it,  and  behind  it,  or  to  one  side,  a  pelvic  mass,  extremely 
sensitive  to  the  touch.  The  average  time  of  rupture  or  tubal 
abortion   is  from  the  eighth  to  twelfth  week  of  pregnanc5'\ 

Diagnosis  and  Differential  Diagnosis. — The  diagnosis 
between  the  different  varieties  of  extra-uterine  pregnancy  is 
made  by  operation,  as  the  clinical  history  and  symptoms  of 
the  tubal,  ovarian  and  abdominal  varieties  are  practically 
identical.  The  differential  diagnosis  from  conditions  closely 
resembling  it  may  be  of  extreme  difficulty.  Two  conditions 
that  are  practically  indistinguishable  from  it  are   (i)   hem- 


l6o  DISEASES    or    THE    FALLOPIAN    TUBES 

orrhage  from  a  ruptured  varicose  vein  in  the  broad  ligament 
and  (2)  severe  hemorrhage  from  the  wall  of  a  ruptured  Graafian 
follicle. 

Others  in  which  a  mistake  is  excusable  are  (3)  acute  sal- 
pingitis with  or  without  coincident  intra-uterine  pregnancy; 
(4)  ovarian  cyst  twisted  on  its  pedicle;  (5)  appendicitis  with 
or  without  coincident  intra-uterine  pregnancy. 

In  salpingitis  there  should  be  a  leukorrheal  discharge; 
higher  fever;  higher  leukocyte  count;  no  decidua  passed; 
less  sensitive  mass;  often  bilateral. 

The  twisted  ovarian  cyst  would  be  spherical  in  shape; 
lower  temperature  (shock);  lower  leukocyte  count,  no  decidua. 
In  appendicitis  the  point  of  tenderness  would  be  over  Mc- 
Burney's  point;  higher  fever,  higher  leukocyte  count,  no 
decidua;  absence  of  a  pelvic  mass. 

The  diagnosis  is  not  so  clear  in  practice.  Acetonuria,  said 
to  be  pathognomonic  of  internal  hemorrhage,  has  proven  of  no 
value  as  a  diagnostic  aid,  as  it  is  found  very  often  in  cases  of 
pyosalpinx.  In  all  cases  in  which  a  diagnosis  of  extra-uterine 
pregnancy  is  justifiable,  the  diagnosis  should  be  made  and  acted 
upon.  All  the  above  require  abdominal  operation,  and  the  only 
mistake  is  that  of  a  possibly  unnecessary  hurried  operation. 

A  common  but  unjustifiable  error  in  diagnosis  is  to  mistake 
extra-uterine  pregnancy  for  an  incomplete  abortion.  In 
incomplete  abortion,  the  cervix  would  be  dilated;  chorion 
would  be  found  in  the  material  discharged  from  the  uterus; 
the  visible  bleeding  would  be  considerably  greater;  shock  is 
less;  no  palpable  pelvic  mass  and  little  if  any  tenderness  in 
the  vaginal  fornix. 

In  cases  of  abdominal  pregnancy,  past  the  sixth  month  of 
development,  the  a;-ray  will  often  afford  a  means  of  clearing  up 
the  diagnosis  between  extra-uterine  pregnancy  and  other  ab- 
dominal tumors  as  the  shadow  of  the  fetal  skeleton  can  be  seen. 

Treatment  is  abdominal  section  as  soon  as  the  diagnosis  is 
made.  The  vaginal  route  is  not  advisable.  After  as  complete 
a  preparation  as  possible  under  the  circumstances,  the  abdomen 


EXTRA-UTERINE    PREGNANCY  l6l 

is  opened  in  the  middle  line,  under  general  or  local  anesthesia. 
When  the  peritoneum  is  reached,  its  color  is  dark  slate,  if 
the  tube  is  ruptured,  from  the  clotted  blood  underneath. 
When  the  peritoneum  is  opened,  the  blood  gushes  forth  in 
large  quantity.  No  attention  should  be  paid  to  it.  The 
affected  tube  and  ovary  should  be  brought  up  into  the  wound, 
ligated  and  removed.  The  blood-clots  are  removed  from  the 
abdomen  best  by  irrigation  with  sterile  water  or  salt  solution. 
The  abdomicn  is  closed  without  drainage.  Rapidity  of  opera- 
tion is  essential.  The  need  for  rapidity  is  over,  however, 
as  soon  as  the  blood-supply  of  the  affected  tube  has  been  con- 
trolled. Any  intravenous  stimulation  or  transfusion  can  be 
done  on  the  table,  during  the  operation.  The  expectant  plan 
of  treatment,  of  waiting  until  the  patient  has  recovered  from 
shock  before  operation,  is  not  to  be  recommended.  Occasion- 
ally these  patients  will  not  rally  from  shock  but  will  bleed  to 
death,  and  nothing  is  gained  by  delayed  operation. 

When  the  pregnancy  has  progressed,  as  it  occasionally  does, 
to  the  latter  months,  the  danger  of  rupture  is  small  and  the 
operator  is  justified  in  waiting  till  the  child  is  viable.  If 
the  child  is  alive,  in  these  cases,  often  extreme  difficulty  will 
be  found  in  controlling  the  bleeding  from  the  placental  site, 
and  packing  will  usually  be  required.  In  cases  where  the 
child  is  dead  and  has  been  long  retained,  the  placenta,  blood- 
clots  and  decidua  are  very  putrescible,  and  drainage  is  uni- 
formly required.  When  the  tube  has  ruptured  into  the  layers 
of  the  broad  ligament,  and  the  patient  has  recovered  from  the 
immediate  shock,  the  resulting  hematoma  is  best  evacuated  by 
incision  through  the  vaginal  vault. 

Active  stimulation  is  the  rule  in  all  bad  cases.  Salt  solu- 
tion intravenously  (2500  mil  or  more)  is  required.  The 
common  mistake  is  in  giving  too  little.  Intravenous  trans- 
fusion of  blood  (500-750  mil  by  Kemp  ton  tube  or  by  sodium 
citrate  method) :  digalen  TUx  or  digipuratum  i  ampule  every 
three  hours  hypodermically :  strychnin  sulph.  grain  3^^o  every 
three  hours  hypodermically;   oxygen  for  a  few  hours  if  very 


1 62  DISEASES    OF    THE    FALLOPIAN    TUBES 

desperate;  and  external  heat  with  bandaged  extremities.  These 
patients  must  be  v/ell  covered  both  on  the  operating  table 
and  afterward  and  surrounded  by  hot  water  bags,  as  they  are 
very  siibject  to  postoperative  pneumonia. 

Prognosis. — Without  operation  66  per  cent,  succumb  to 
internal  hemorrhage.  Of  the  remaining  34  per  cent,  a  large 
proportion  are  invalids  or  ultimately  lose  their  lives  from 
complications  directly  a  result  of  the  extra-uterine  preg-^ 
nancy  (suppurating  pelvic  hematoma,  etc.).  With  abdominal 
section,  the  mortality  should  be  very  small  (i  per  cent,  or  less), 
if  seen  in  time,  and  few,  if  any,  cases  are  too  desperate  for 
operation.  A  few  cases  will  first  rally  and  then  die  of  acute 
anemia,  in  spite  of  stimulation.  Postoperative  pneumonia 
is  a  common  and  dangerous  complication. 

Pregnancy  in  one  horn  of  a  uterus  unicornis  or  bicomis, 
sometimes  occurs.  It  cannot  usually  be  diagnosed  from  tubal 
pregnancy  and  its  complications  and  treatment  are  the  same. 
It  will  probably  rupture  at  the  cornu  of  the  uterus,  but  later 
in  pregnancy  than  the  tubal  variety.  The  ovum  may,  however, 
be  expelled  through  the  cervix,  as  in  ordinary  abortion. 

A  true  cornual  pregnancy  may  either  rupture  at  the  third 
or  fourth  month,  or  more  likely  spontaneously  move  into  the 
uterine  cavity  and  continue  to  term. 

Metrorrhagia  after  operation  for  ectopic  pregnancy  is  due  to 
hypertrophied  angiomatous  decidua.  When  it  occurs,  any 
time  spent  in  palliative  measures  is  wasted.  Dilatation  and 
curetment  is  the  only  cure. 

Removal  of  both  tubes,  with  the  idea  of  preventing  a  second 
ectopic,  is  not  justified,'  unless  the  other  tube  shows  marked 
evidence  of  inflammation.  At  least  33  per  cent,  of  all  cases 
have  normal  intrauterine  pregnancies  later,  while  less  than 
15  per  cent,  have  a  repeated  ectopic. 

IV.  HEMATOSALPINX 

Hematosalpinx  is  a  collection  of  blood  in  the  closed  tube. 
Causes. — (i)  Extrauterine  pregnancy;  (2)  acute  tubal  conges- 


HYDROSALPINX  1 63 

tion;  (3)  acute  tubal  inflammation  (gonorrheal) ;  (4)  associated 
with  gynatresia;  (5)  tubal  menstruation. 

The  form  associated  with  gynatresia  differs  from  the  others 
in  being  liable  to  cause  fulminant  infection  of  the  peritoneum 
if  it  ruptures. 

Sjonptoms  are  those  of  salpingitis.  The  diagnosis  of  the 
true  condition  is  made  on  inspection,  as  the  mass  palpable 
by  vaginal  examination  differs  little  if  at  all  from  the  ordinary 
pyosalpinx. 

Treatment  is  abdominal  section,  with  removal  of  the  tube 
affected. 

V.  HYDROSALPINX  (HYDROPS  TUB^;  SACROSALPINX 
SEROSA) 

This  is  a  collection  of  serum  or  thin  mucus  in  the  closed  tube. 

Pathology. — The  tube  is  markedly  distended,  the  walls  very 
thin  and  almost  transparent;  perisalpingitis  is  present,  and 
the  cause  of  the  closed  abdominal  end  of  the  tube,  but  no 
inflammatory  condition  of  the  tube  itself  need  be  present.  The 
mucosa  has  almost  or  quite  disappeared.  Rarely  the  tubal 
walls  are  thickened  by  inflammation.  The  condition  is  usually 
bilateral  and  is  a  sequel  of  gonorrheal  or  puerperal  infection. 
The  tubes  are  moderate  in  size,  because  the  thin  walls  permit 
a  certain  amount  of  leakage,  when  the  tension  becomes  great. 

Varieties. — ^(i)  Simple  hydrosalpinx;  (2)  pseudofollicular, 
where  the  atrophied  mucosa  suggests  gland  spaces;  (3)  hydrops 
tubge  profluens;  (4)  tubo-ovarian  cyst. 

Symptoms.^ — All  give  symptoms  of  moderate  pelvic  Inflam- 
mation, but  the  tenderness  on  palpation  is  much  less  than  in 
salpingitis.  Hydrops  tubas  profluens  or  recurrent  hydro- 
salpinx is  the  name  given  to  the  variety  which  periodically 
empties  itself  through  the  uterine  cavity,  as  evidenced  by 
increasing  discomfort,  a  gush  of  fluid  from  the  vagina,  and 
then  relief  from  discomfort  until  the  sac  has  refilled. 

Diagnosis. — Bimanual  examination  shows  a  fixed  uterus 
and  a  palpable  pelvic  mass  behind  it.     The  diagnosis  will 


164  DISEASES    OF    THE    FALLOPIAN    TUBES 

usually  be  salpingitis,  though  the  true  condition  may  be  sus- 
pected by  the  lack  of  great  tenderness.  Hydrops  tubs 
profluens,  due  to  the  periodic  gushes  of  fluid,  is  sufficiently 
obvious  to  avoid  a  mistaken  diagnosis. 

Treatment. — Abdominal  section,  removing  the  tubes  but 
conserving  ovarian  tissue  where  possible. 

VI.  SALPINGITIS 

Salpingitis,  or  inflammation  of  the  Fallopian  tubes  is  of 
two  kinds:  (i)  Non-infectious;  (2)  infectious,  the  latter  being 
much  the  commoner. 

The  non-infectious  variety  is  due  to  cold,  injuries  or  the 
escape  into  the  tubes  of  such  fluids  as  iodin,  nitrate  of  silver 
or  other  solutions  used  in  local  application  to  the  uterine 
cavity.  It  is  of  short  duration,  marked  by  a  few  days  of 
acute  pain  from  pelvic  peritonitis,  and  relieved  by  palliative 
treatment. 

Bacteria  in  infectious  salpingitis  are:  (i)  Gonococcus; 
(2)  streptococcus;  (3)  tubercle  bacillus;  (4)  Bacillus  coli  com- 
munis; (5)  staphylococcus.  This  is  approximately  their  order 
of  frequency.  Most  pathogenic  bacteria  can  be  the  cause  of 
salpingitis,  but  the  five  given  account  for  the  vast  majority 
of  cases. 

Gonococci,  responsible  for  more  than  any  other  organism, 
pass  the  barrier  of  the  internal  os  usually  just  after  a  menstrual 
period.  This  may  not  occur  for  months  or  years  after  the 
original  infection.  They  do  very  little  harm  to  the  endome- 
trium of  the  uterine  body,  but  find  productive  soil  for  growth 
in  the  tubal  mucosa. 

Streptococci  are  introduced  after  labor,  miscarriage  or  dirty 
instrumentation,  and  very  rarely  by  hematogenous  infection 
from  acute  foci  in  other  parts  of  the  body  (notably  the  tonsils). 

Stages. — Every  case  of  salpingitis,  except  possibly  the 
tubercular  passes  through  two  stages:  (i)  acute;  (2)  chronic. 

Pathology. — (i)  Acute  Stage,  (i)  The  mucosa  is  swollen, 
red  and  edematous;  (2)  the  mucosa  and  fimbria  are  bathed 


SALPINGITIS 


165 


in  a  purulent  exudate;  (3)  the  tube  is  elongated,  thickened  and 
stiff;  (4)  the  abdominal  end  is  open  and  there  is  free  exit  for 
pus  into  the  peritoneal  cavity;  (5)  there  is  marked  round-cell 
infiltration  of  both  mucosa  and  tubal  wall.  This  is  the  stage 
of  purulent  salpingitis. 

(2)  Chronic  Stage. — (i)  The  tube  cell  is  markedly  thickened; 
(2)  the  abdominal  ostium  is  closed;  (3)  the  tubal  lumen  is 
distended  by  pus,  this  being  most  marked  in  the  outer  two- 
thirds  of  the  tube;  (4)  the  uterine  end  is  closed  off  and  the 


Pig.  65. — Acute  double  purulent  salpingitis.     The  ampullse  of  both  tubes 
are  open  and  dripping  pus.      {After  Graves.) 

tube  becomes  a  closed  sac,  which  may  grow  to  very  considerable 
size;  (5)  the  epithelial  layer  loses  many  of  its  folds  as  all  of 
its  cilia,  and  the  remaining  folds  adhere  to  each  other;  (6) 
the  tube  is  elongated,  convoluted,  and  bound  down  by  dense 
adhesions  to  the  posterior  layer  of  the  broad  ligament  and 
posterior  uterine  wall;  (7)  local  hypertrophy  is  seen  any- 
where in  the  course  of  the  tube,  but  most  commonly  as  a 
marked  elevation  at  the  uterine  cornu — salpingitis  isthmica 
nodosa;  (8)  the  blood-vessel  walls  in  the  muscular  coat  show 
hyaline  degeneration.  This  is  the  stage  of  pyosalpinx  or 
pus-tube.     Not  infrequently  the  fimbriated  extremity  is  closed 


i66 


DISEASES    OF    THE    FALLOPIAN    TUBES 


by  adhesion  to  the  ovary,  over  the  site  of  a  Graafian  follicle. 
This  follicle  ruptures  and  pus  from  the  tube  invades  the  ovarian 


LeffTubo-Ovar I  an  Abscess     r^ 


W^i  Tubed  Abscess 


Pig.   66. — The  type  of  adhesions  found  in  double  gonorrheal  pyosalpinx. 
(After  Graves.) 


Fig.   67. — Salpingitis  isthmica  nodosa:  a  type  of  bilateral  gonorrheal  pyo- 
salpinx.     (After  Graves.) 

substance.     Gradually  the  whole  ovary  is  invaded  and  con- 


SALPINGITIS  167 

verted  into  a  pus-sac  continuous  with  the  tube.  Even  if  both 
ovaries  are  involved,  the  ovarian  tissue  is  never  wholly  de- 
stroyed, as  menstruation  does  not  cease.  The  ovary  is  per- 
manently damaged,  however,  and  usually  must  be  removed  at 
operation  with  the  offending  tube.  This  is  a  tuho-ovarian 
abscess. 

How  the  Ends  of  the  Tube  are  Closed. — (i)  By  adhesion  and 
retraction  of  the  fimbria,  probably  the  commonest  way;  (2) 
by  adhesions  in  Douglas'  pouch  around  the  fimbria,  which  shut 
off  the  tubal  lumen  from  the  peritoneal  cavity,  though  the 
lumen  itself  is  open;  (3)  by  adhesions  of  the  fimbria  to  the 
surface  of  the  ovary  and  formation  of  a  tubo-ovarian  abscess. 

A  pyosalpinx  results  only  after  the  tube  is  closed;  as  long  as 
the  tube  is  open  it  is  called  purulent  salpingitis. 

After  the  tube  is  closed  off,  the  bacteria  contained  in  the 
pus  gradually  die,  being  destroyed  by  the  compression  in  the 
distended  tube,  and  lack  of  fresh  infection  from  the  uterine 
cavity.  The  pus  becomes  sterile  usually  three  or  four  weeks 
after  the  tube  is  closed,  but  is  liable  to  fresh  infection  from  the 
uterine  cavity,  by  ill-advised  curetment,  or  from  the  bowel, 
at  any  time. 

Bacteria  may  be  found  in  the  pus  in  acute  cases,  when  the 
abdominal  ostium  is  still  open.  It  is  useless  to  look  for  them 
in  slides  made  from  the  pus  from  the  ordinary  closed  pyosalpinx. 
This  sterility  of  the  pus  explains  why  such  a  tube  can  be  rup- 
tured at  operation  with  impunity,  and  the  abdomen  closed 
without  drainage;  a  thing  never  possible  in  an  appendicial 
abscess,  for  instance. 

Pelvic  peritonitis  is  always  present  in  acute  salpingitis, 
because  the  seropurulent  discharge  from  the  open  abdominal 
ostium  inevitably  flows  into  the  peritoneum  of  Douglas'  pouch. 
This  causes  the  dense  adhesions  in  and  following  salpingitis, 
usually  spoken  of  as  chronic  pelvic  inflammatory  disease.  The 
older  the  infection  the -denser  the  adhesions;  and  above  all 
other  infections  they  are  densest  in  syphilis.  The  adhesions 
involve  the  bladder,  pelvic  organs,  intestines,  and  in  severe 


1 68 


DISEASE'S    OF    THE    FALLOPIAN    TUBES 


cases  the  whole  pelvis  is  filled  with  a  conglomerate  mass  of  the 
organs  affected.  These  are  the  most  serious  cases,  due 
to  the  danger  of  bowel  injury  and  intestinal  obstruction. 

Sjnnptoins  differ  markedly  in  the  acute  and  chronic  stages. 
The  s3nnptoms  of  chronic  pyosalpinx  and  tubo-ovarian 
abscess  are  identical. 

Symptoms  of  the  Acute  Stage. — (i)  Acute  abdominal  pain, 
most  marked  in  the  lower  abdomen;  (2)  rigidity  of  the  abdom- 


FiG.  68. — Double  gonorrheal  salpingitis,  showing  the  extent  of  adhe- 
sions usually  met  with.  It  is  these  adhesions  and  the  necessary  trauma  in 
separating  them  that  is  responsible  for  the  danger  in  these  operations. 
{After  Graves.) 

inal  muscles,  much  greater  in  the  lower  than  the  upper  portion; 
(3)  great  increase  of  pain  on  any  muscular  exertion,  or  any 
jolt  or  jar,  such  as  sneezing,  coughing  etc.;  (4)  temperature 
elevated,  the  average  being  about  102,  except  in  streptococcic 
infection,  where  it  is  much  higher;  (5)  leukocytosis  18,000  to 
20,000;  (6)  leukorrheal  discharge. 

Bimanual  examination  shows  a  uterus  fixed  and  immovable; 
(2)  excessive  pain  on  touching  either  vaginal  vault;  (3)  rarely 


SALPINGITIS  169 

in  the  acute  stage  a  palpable  mass  for  two  reasons:  (i)  The 
abdominal  end  of  the  tube  is  still  open  and  the  tube  is  moderate 
in  size  and  (2)  the  excessive  tenderness  prevents  any  deep 
examination.  The  acute  pain  in  these  cases  is  due  to  leakage 
of  pus  from  the  open  abdominal  end  of  the  tube  into  the  peri- 
toneum of  Douglas'  pouch,  and  a  sharp  pelvic  peritonitis. 
These  attacks  of  pain  recur  at  intervals  until  the  tube  is  closed 
and  no  further  leakage  is  possible. 

Differential  diagnosis  must  be  made  from  extra-uterine 
pregnancy,  acute  appendicitis  and  ovarian  cyst  twisted  on  its 
pedicle.  Accurate  diagnosis  is  a  matter  of  importance,  be- 
cause it  is  highly  desirable  to  avoid  abdominal  section  in  the 
acute  stage  of  salpingitis,  due  to  the  risk  of  diffuse  peritonitis. 

Extra-uterine  Pregnancy.- — ^(i)  Cessation  of  menses  and  then 
irregular  bleeding;  (2)  violent  pain,  paroxysmal,  with  evidence 
of  shock;  (3)  discharge  of  decidua  and  usually  absence  of 
leukorrhea;  (4)  temperature  only  99.5  to  100;  (5)  leukocytosis 
rarely  over  14,000;  (6)  confirmatory  signs  of  pregnancy. 

Acute  Appendicitis. — -(i)  Pain  higher  up ;  (2)  tempera- 
ture and  leukocyte  count  about  the  same;  (3)  no  vaginal  ten- 
derness; (4)  uterus  not  fixed;  (5)  no  palpable  mass;  (6)  absence 
of  leukorrhea. 

Ovarian  Cyst  Twisted  on  its  Pedicle. — (i)  Severe  shock;  (2) 
absence  of  fever,  leukocytosis  and  leukorrhea;  (3)  uterus 
displaced  forward  and  to  one  side  by  a  globular  mass  filling 
the  pelvis.  The  diagnosis  is  often  one  of  extreme  difficulty, 
if  not  impossibility,  and  immediate  operation  will  often  be 
decided  upon,  based  upon  a  mistaken  diagnosis. 

Positive  smears  for  gonococci,  the  gonorrheal  stigmata,  and 
positive  complement  fixation  test  are  strong  arguments  in 
favor  of  salpingitis  and  against  the  other  possibilities. 

Sjnnptoms  of  the  Chronic  Stage.^ — (i)  History  of  leukorrheal 
discharge,  usually  of  long  standing;  (2)  history  of  repeated 
attacks  of  sharp  pain,  recurring  at  intervals;  (3)  present 
history  of  constant  dragging  pain  in  lower  abdomen;  (4)  pain 
invariably  increased  by  the  premenstrual  congestion,  relieved 


170  DISEASES    OF    THE    FALLOPIAN    TUBES 

by  the  flow,  and  returning  when  the  flow  ceases;  (5)  menor- 
rhagia;  (6)  pain  increased  by  any  muscular  exertion,  coitus,  or 
defecation;  (7)  usually  secondary  anemia,  due  to  toxemia; 
(8)  pain  is  often  referred  to  distant  regions,  as  headache, 
backache  or  in  the  nape  of  the  neck;  (9)  nearly  always  a  history 
of  neurasthenia,  digestive  disturbances  and  chronic  consti- 
pation, due  to  the  pelvic  disease;  (10)  rarely,  even  extensively 
inflamed  and  adherent  tubes  may  give  rise  to  very  little  local 
disturbance  and  present  practically  no  symptoms.  Usually, 
however,  patients  with  chronic  salpingitis  look  prematurely 
aged,  anxious  and  worn. 

Diagnosis. — Abdominal  palpation  shows  marked  tenderness 
to  deep  pressure  over  the  lower  abdomen,  but  rarely  a  palpable 
mass. 

Bimanual  Examination. — (i)  The  uterus  is  fixed  and  im- 
movable, and  almost  always  shows  some  backward  displace- 
ment; (2)  there  is  a  hard,  irregular,  sensitive  mass  fiUing 
Douglas'  pouch,  in  which  it  may  be  possible  to  outline  the 
tubes,  ovaries  and  posterior  uterine  wall;  (3)  rarely  the  tubal 
mass  lies  in  front  of  the  uterus;  (4)  pressure  on  the  tubes 
always  causes  considerable  pain  and  is  often  agonizing;  (5) 
the  cervix  is  usually  eroded  and  there  is  profuse  leukorrheal 
discharge. 

Differential  Diagnosis. — (i)  Retroversion  of  the  uterus  may 
be  excluded  by  the  irregularity  of  the  mass  filling  Douglas' 
pouch  and  by  the  symptoms  given  above  for  chronic  sal- 
pingitis. (2)  An  old  pus  tube,  densely  adherent  in  Douglas' 
pouch  and  to  the  back  wall  of  the  uterus,  is  often  so  hard  and 
unyielding  as  to  be  mistaken  for  a  subperitoneal  fibroid,  or 
for  a  retroverted  uterus.  (3)  In  gonorrheal  cases,  the  comple- 
ment-fixation test  is  of  value,  as  a  differential  point,  but  is 
negative  until  at  least  four  weeks  after  the  onset  of  gonorrhea. 

(4)  Other  possibilities  are  as  given  under  acute  salpingitis. 

(5)  A  pus  tube  may  rupture  and  cause  diffuse  peritonitis,  but 
this  is  so  rare  that  the  presence  of  acute,  diffuse  peritonitis 
points  strongly  toward  the  appendix  as  origin  of  the  infection. 


SALPINGITIS 


171 


(6)  Diverticulitis  of  the  sigmoid  is  almost  impossible  to 
diagnose  from  left-sided  salpingitis.  It  usually  occurs  in 
women  beyond  the  age  at  which  salpingitis  is  likely,  but  in 
other  respects  is  indistinguishable. 


DIFFERENTIAL  DIAGNOSIS  BETWEEN  GONORRHEAL  AND 
STREPTOCOCCIC  PYOSALPINX 


Gonorrhea 
(i)  Can  occur  at  any  time. 

(2)  Often  bilateral. 

(3)  Cornual  abscess  rare. 

(4)  Abdominal   end   of   the    tube 
closed. 

(5)  Tube  lengthened,   convoluted 
and  adherent. 

(6)  Broad  ligament  rarely  thick- 
ened. 

(7)  Infection  travels  to  tube  under 
mucosa. 

(8)  Ovary  affected  secondarily. 

(9)  Temperature  101-102. 

(10)  Leukocytosis  18,000  plus. 

(11)  Rarely  a  palpable  abdominal 
mass. 

(12)  Gonorrheal  stigmata   (Skene's 
and  Bartholin's  glands)present. 

(13)  Complement-fixation  test  posi- 
tive. 

(14)  Gonococci  in  discharge. 


Streptococcic  Infection 

(i)  Rare  except  after  miscarriage 
or  labor. 

(2)  Most  often  unilateral. 

(3)  Cornual  abscess  common. 

(4)  Abdominal  end  of  tube  open. 

(s)  Tube  thick  friable,  beefy  and 
dark  red. 

(6)  Broad  ligament  always  thick- 
ened. 

(7)  Infection  travels  to  tube 
through  lymphatics  of  broad 
ligament. 

(8)  Ovary  affected  primarily. 

(9)  Temperature  104-105. 

(10)  Leukocytosis  25,000  plus. 

(11)  Usually  a  palpable  abdominal 
mass,  due  to  omentum  ad- 
herent cornu. 

(12)  Gonorrheal  stigmata  absent. 

(13)  Complement-fixation  test  nega- 
tive. 

(14)  Streptococci  in  discharge. 


Treatment  of  Salpingitis 

I.  Acute  Stage,  Palliative  Treatment. — Acute  salpingitis, 
except  the  streptococcic  form,  is  rarely  fatal,  the  peritonitis 
is  limited  to  that  portion  of  the  pelvis  where  absorption  is 
slowest,   and   the   disease   tends  to   subside  either  partially 


172  DISEASES    OF    THE    FALLOPIAN    TUBES 

or  completely  in  six  to  ten  days.  The  treatment,  therefore, 
is  expectant. 

(i)  Rest  in  bed;  (2)  liquid  or  soft  diet;  (3)  four  hot  vaginal 
douches  a  day,  using  normal  saline  solution,  as  hot  as  the 
patient  can  bear  them;  (4)  ice-bag  constantly  to  lower  ab- 
domen; (5)  bowels  kept  well  open  (best  by  magnesium  citrate 
solution /a^,  oz.  4  twice  daily)  (6)  for  the  minority  of  patients 
to  whom  heat  is  more  grateful  than  the  ice-bag,  a  hot  flaxseed 
poultice  to  lower  abdomen,  or  hot  water  bag  constantly; 
(7)  no  local  vaginal  treatment  such  as  tampons  or  applications 
(other  than  the  douches  mentioned  above);  (8)  leukocyte 
count  daily;  (9)  above  all,  no  curettage  or  other  intra-uterine 
applications. 

This  treatment  will  usually  cause  temperature,  pulse  and 
leukocyte  count  to  drop  normal  inside  of  three  to  seven  days, 
and  all  pain  to  disappear.  Should  the  leukocyte  count  steadily 
rise,  or  should  a  diiferential  diagnosis  between  salpingitis  and 
extra-uterine  pregnancy  be  impossible,  prompt  operation  is 
the  safest  course,  though  there  is  some  danger  of  diffuse 
peritonitis  and  the  case  will  probably  require  drainage.  If 
there  is  a  bulging  mass  in  Douglas'  pouch,  vaginal  puncture  is 
the  proper  procedure;  otherwise  abdominal  section  is  necessary. 

Palliative  treatment,  in  the  chronic  stage  is  usually  a  waste 
of  time.  Except  in  cases  of  acute  exacerbation  of  a  chronic 
process,  which  are  treated  as  the  acute  form,  not  much  if 
anything  can  be  gained.  If  the  patient's  complaint  is  pain 
and  there  is  no  palpable  mass, palliative  treatment  is  desirable; 
if  a  mass  is  present,  nothing  permanent  can  be  expected  from  it. 
(i)  Rest  in  bed  during  menstrual  periods,  and  avoidance  of 
physical  exertion  at  other  times;  (2)  avoidance  of  coitus  or  any 
other  cause  of  pelvic  congestion;  (3)  hot  vaginal  douching 
three  times  daily;  (4)  application  of  5  per  cent,  iodin  to  vaginal 
vaults  three  times  a  week;  (5)  boroglycerid  or  ichthyol 
tampons,  renewed  three  times  a  week  (see  chapter  on  office 
treatment);  (6)  no  curetment,  unless  it  is  to  be  followed 
immediately  by  abdominal  section. 


SALPINGITIS  173 

OPERATIVE  TREATMENT  OF  ACUTE  AND  CHRONIC  SALPINGITIS 

Indications. — (i)  Where  a  large  tubal  mass  is  palpable; 
(2)  when  palliative  treatment  has  failed  to  give  relief;  (3)  in 
cases  with  great  pain,  unrelieved  by  treatment;  (4)  in  working 
women,  who  cannot  afford  the  time  required  for  palliative 
treatment;  (5)  in  acute  cases,  where  there  are  signs  of  diffuse 
peritonitis,  or  a  pelvic  mass  develops. 

Operations. — (i)  Breaking  of  adhesions,  without  removal  of 
any  of  the  pelvic  organs;  {2).  salpingectomy — removal  of  the 
tube  alone;  (3)  salpingo-oophorectomy — removal  of  both 
tube  and  ovary;  (4)  salpingostomy — reopening  a  closed 
tube,  in  sterility;  (5)  hysterectomy,  with  removal  of  both 
tubes  and  ovaries  as  well;  (6)  vaginal  section,  with  breaking 
up  of  adhesions,  or  drainage  of  an  abscess  or  of  the  tubes 
themselves.  As  it  is  not  possible,  before  operation,  to  judge 
how  much  must  be  removed,  it  is  always  wisest  to  obtain 
written  consent  of  both  the  patient  and  her  husband,  or  some 
other  responsible  member  of  the  family,  to  do  whatever  in 
the  surgeon's  judgment  seems  necessary. 

(i)  Breaking  up  of  adhesions,  may  be  done  either  by  the 
vaginal  route  (undesirable)  or  by  abdominal  section.  It  is 
indicated  only  when  there  is  no  gross  change  in  the  tubes 
themselves,  and  the  tubes  are  simply  bound  down  by  adhesions. 
The  tubes  are  rolled  out  of  the  bed  of  adhesions  holding  them, 
by  pressure  from  below  upward  and  behind  forward.  This 
minimizes  the  danger  of  injury  to  the  bowel.  The  prospect 
of  permanent  success  is  not  brilliant.  In  the  majority  of  cases, 
the  adhesions  promptly  "reform. 

(2)  Salpingectomy — removal  of  the  tube  alone,  by 
abdominal  section. 

Technic. — ^i .  The  tube  is  freed  from  adhesions  and  delivered 
through  the  wound. 

2.  It  is  grasped  with  one  hemostat  at  the  cornu  of  the 
uterus  and  by  another  just  below  the  fimbriated  extremity, 
above  the  ovary. 


174  DISEASES    or    THE    FALLOPIAN    TUBES 

3.  The  tube  is  cut  loose  from  the  cornu  by  a  wedge-shaped 
excision  of  the  uterine  muscle. 

4.  It  is  cut  loose  from  the  mesosalpinx,  each  vessel  being 
clamped  as  it  is  cut;  four  or  five  hemostats  are  needed. 

5.  With  a  number  i  chromic  catgut  stitch,  soaked  in  water 
so  as  to  be  pliable,  the  cornu  and  upper  edge  of  the  broad 
ligament  are  sewed  over,  taking  a  half  hitch  at  each  stitch, 
A  simple  running  stitch  is  not  hemostatic.  This  stitch  is 
tied  at  the  cornu,  where  it  begins,  and  again  outside  the  outer 
hemostat. 

6.  One  or  two  small  mattress  stitches,  to  secure  bleeding 
points  may  be  required. 

This  has  the  great  advantage  over  other  methods  that  it  does 
not  distort  the  broad  ligament,  and  that  slipping  of  the  ligature, 
provided  the  catgut  is  pliable,  is  hardly  possible.  The  method 
is  not  possible  if  the  broad  hgament  is  infiltrated  and  stiff. 

Alternative  Method. — (i)  A  ligature  of  number  3  chromic  cat- 
gut is  passed  through  the  broad  ligament  under  the  round  liga- 
ment; (2)  the  tube  is  cut  loose  from  the  cornu;  (3)  the  first 
ligature  is  tied  under  the  excised  end  of  the  tube;  (4)  a  second 
ligature  is  placed  near  the  first  and  tied  down,  across  the  whole 
mesosalpinx,  just  above  the  ovary;  (5)  the  tube  is  cut  off; 
(6)  the  cornual  wound  is  closed. 

The  outer  ligature  in  this  method  is  prone  to  slip,  especially 
if  the  mesosalpinx  is  stiff. 

The  tube  may  be  removed  by  anterior  vaginal  section,  under 
the  bladder,  dehvering  the  uterus  out  under  the  bladder  and 
then  the  tube  removed  by  either  of  the  methods  described 
above.  The  small  amount  of  working  space  and  the  difficulty 
in  dealing  with  adhesions  make  the  method  undesirable. 

(3)  Salpingo-oophorectomy^ — removal  of  tube  and  ovary,  is 
indicated  when  the  ovary  is  badly  damaged,  or  forms  part  of 
the  wall  of  an  abscess. 

Technic. — (i)  The  tube  and  ovary  are  freed  from  their  bed 
and  delivered  in  the  wound;  (2)  the  tube  is  grasped  at  the  cornu 
with  a  hemostat;  (3)  a  second  hemostat  grasps  the  free  ovarian 


SALPINGITIS 


175 


edge  of  the  broad  ligament;  (4)  the  tube  is  excised  at  the 
cornu  and  tube  and  ovary  are  removed  together  by  cutting 
across  the  upper  edge  of  the  broad  Hgament,  clamping  vessels 
as  they  are  cut;  (5)  the  cornu  and  broad  ligament  wounds  are 
closed  by  a  running  lock  stitch  (half  stitch)  of  number  i 
chromic  catgut,  pliable,  as  in  salpingectomy. 

This  is  the  ideal  method,  but  is  not  always  possible  because 
for  it  the  broad  ligament  must  be  free  from  infiltration. 

Alternative  Method. — (i)  The  tube  and  ovary  are  freed  as 
before;  (2)  a  ligature  of  number  3  chromic  catgut  is  passed 
through  the  broad  ligament,  under  the  round  ligament,  close 


'm-. 


Fig.  69. — The  condition  often  found  at  operation  for  gonorrheal  pyo- 
salpinx.  The  bowel  is  extensively  involved  in  dense  adhesions.  {After 
Crossen.) 


to  the  uterus;  (3)  the  tube  is  excised  at  the  cornu  and  the 
ligature  tied  under  the  excised  end.  This  secures  the  uterine 
artery;  (4)  a  second  ligature  is  passed  through  the  broad  liga- 
ment, near  the  first  and  tied  on  the  free  ovarian  edge  of  the 
broad  ligament;  (5)  the  ovarian  artery  is  tied  again,  just  be- 
yond this  ligature,  as  the  free  edge  of  the  broad  ligament  has 
a  strong  tendency  to  slip  from  the  bite  of  the  single  ligature. 
From  this  edge  of  the  broad  ligament  come  most  of  the  second- 
ary hemorrhages  after  operation;  (6)  the  ovary  and  tube  are 
removed;  (7)  the  cornu  is  closed  and  with  the  same   stitch, 


176  DISEASES    or    THE    FALLOPIAN    TUBES 

the  cut  edge  of  the  broad  ligament  is  whipped  over.  This  is 
the  best  method,  when  the  broad  Hgament  is  infiltrated. 

Vaginal  section  for  salpingo-odphorectomy  is  open  to  the 
same  objection  as  for  salpingectomy. 

Conservatism  is  rnost  desirable  in  these  operations.  It  is 
often  possible  to  remove  the  outer  portions  of  the  tubes  only, 
and  do  an  ovarian  resection,  so  as  to  leave  at  least  part  of  the 
adnexa,  if  they  are  reasonably  free  from  pathological  changes. 
There  is  some  chance  of  future  trouble  necessitating  a  second 
operation  and  this  should  be  explained  to  the  patient  before 
operation,  and  the  choice  left  with  her. 

(4)  Hysterectomy  is  usually  not  necessary,  unless  the  uterus 
itself  is  greatly  diseased.  Even  if  both  tubes  and  ovaries 
have  been  sacrificed,  the  uterus  is  not  a  useless  organ.  It 
affords  marked  support  for  the  vaginal  vaults,  and  the  two 
objections  to  leaving  it  (leukorrhea  and  metrorrhagia)  can 
be  met  by  the  curetment  which  should  always  precede  any 
section  for  pelvic  inflammatory  disease,  except  that  due  to 
streptococcic  infection.  If  hysterectomy  is  required,  the 
technic  is  exactly  that  described  in  the  removal  of  a  fibroid 
tumor  (Chapter  VII). 

In  all  the  operations  thus  far  described,  an  important  step 
is  to  pack  off,  with  gauze,  the  upper  abdominal  cavity,  above 
the  pelvic  brim,  to  prevent  contamination  if  an  abscess  is 
opened  into.  This  is  desirable  in  any  case;  it  is  absolutely 
essential  in  streptococcic  cases. 

(5)  Salpingostomy  is  the  reopening  of  closed  tubes,  either 
by  dilatation  of  the  fimbriated  extremity  or  by  cutting  a 
window  in  the  side  of  the  tube,  for  the  possible  relief  of  sterility. 

Technic. — (i)  The  tube  is  delivered  into  the  wound;  (2) 
with  scissors  a  small  opening  is  made  over  the  closed  fimbriated 
end;  (3)  a  hemostat  is  inserted  in  this  opening  and  the  blades 
opened,  to  dilate  it,  this  method  causing  a  minimum  of  trauma, 
or  a  window  is  cut  in  the  side  of  the  tube,  in  its  outer  third,  and 
the  mucosa  united  to  the  serous  coat  with  interrupted  sutures. 

The  results  are  not  satisfactory;  only  rarely  has  pregnancy 


SALPINGITIS  177 

resulted,  and  there  is  considerable  risk  of  extra-uterine  preg- 
nancy, rather  than  intra-uterine. 

(6)  Vaginal  section  and  drainage,  while  usually  undesirable, 
has  a  field.  In  acute  cases,  with  large  pelvic  mass,  or  in  the 
profound  cachexia  seen  with  large  chronic  tubes  it  is  decidedly 
useful. 

Technic.—{i)  The  patient  is  arranged  in  the  lithotomy 
position  and  prepared  as  for  any  vaginal  operation;  (2)  the 
posterior  lip  of  the  cervix  is  caught  with  a  tenaculum  and 
pulled  up  toward  the  symphysis;  (3)  a  semicircular  incision 
is  made  through  the  vaginal  vault,  and  with  a  pair  of  scissors, 
inserted  close  to  the  uterus  and  in  the  middle  line,  the  mass  is 
punctured  and  the  scissors  withdrawn  open;  (4)  the  cavity 
is  explored  with  the  finger,  as  far  as  it  will  reach,  and  then 
washed  out;  (5)  the  cavity  is  drained  with  gauze  (if  not  much 
pus  has  escaped)  or  with  a  T-drainage  tube,  and  irrigated  daily 
until  all  discharge  has  ceased.  This  method  is  indicated  to 
relieve  the  acute  septic  symptoms  and  as  a  preparation  for  a 
subsequent  abdominal  section. 

Drainage  in  abdominal  sections  is  needed  in  many  cases 
for  (i)  persistent  oozing  from  the  posterior  wall  of  the  uterus, 
broad  ligaments  and  Douglas'  pouch  or  (2)  infection.  The  best 
method  is  a  glass  tube  and  gauze,  through  the  lower  end  of  the 
abdominal  incision.  Drainage  into  the  vagina  through  the 
posterior  vaginal  vault  is  satisfactory  for  hemorrhage  but  not 
for  infection,  and  especially  not  for  the  streptococcic  kind. 
Drainage,  its  method  and  after  care  is  described  in  Chapter  X 
under  peritonitis  and  pelvic  abscess.  Two  classes  of  patients 
do  not  admit  of  drainage: 

(i)  Tubercular  salpingitis,  because  drainage  means  a  per- 
manent abdominal  fistula. 

(2)  Syphilis,  because  around  the  gauze  there  is  such  an 
exudate  of  lymph  that  the  whole  pelvis  is  filled  by  a  solid  mass 
and  there  is  great  danger  of  intestinal  obstruction. 

Sterility  after  double  salpingo-oophorectomy  is  almost  in- 
variable, though  pregnancy  may  result  from  the  remains  of  an 


178  DISEASES    OF    THE   FALLOPIAN    TUBES 

ovary  left  adherent  to  the  broad  ligament,  the  ovum  gaining 
access  to  the  uterine  cavity  through  the  uterine  cornu,  which 
has  not  healed  tight.  Efforts  at  transplantation  of  the  ovary, 
from  the  same  or  another  patient,  and  sewing  it  into  the  cornu 
have  not  been  successful.  In  any  case  the  patient  should  not 
be  told  she  is  sterile,  as  the  mental  effect  on  her  is  often 
unfortunate. 

The  surgical  menopause,  which  is  the  more  severe  the 
younger  the  patient,  can  be  controlled  by  hypodermic  intra- 
muscular injections  of  corpus  luteum  extract  or  whole  ovarian 
extract;  i  mil  daily  for  thirty  doses  and  repeated  in  series  of 
twelve  doses  at  intervals  of  several  months,  if  needed. 

This  method  is  better  and  more  certain  in  its  results  than 
the  implantation  in  the  abdominal  wall,  next  the  fascia,  of 
ovarian  tissue.  If  this  latter  is  done,  it  is  important  to  use 
only  ovarian  grafts  (slices)  and  not  the  whole  ovary.  The 
thin  grafts  are  not  subject,  as  is  the  whole  ovary,  to  cystic 
degeneration. 

Removal  of  both,  tubes  in  cases  known  to  be  gonorrheal, 
where  one  is  obviously  infected,  is  a  matter  of  individual 
choice.  It  should  be  explained  to  the  patient  beforehand  that 
the  disease  is  most  often  bilateral,  and  that  she  might  need  a 
second  operation  within  one  or  two  years,  if  the  at  present 
inoffensive  tube  is  left,  and  the  choice  left  with  her.  The 
wisest  plan  is  to  obtain  consent  for  whatever  is  necessary 
in  the  surgeon's  judgment,  and  be  as  conservative  as  possible. 
If  the  second  tube  shows  evidence  of  beginning  inflammation, 
it  is  better  removed;  if  it  is  free  from  all  signs,  it  may  be  left, 
but  with  some  misgivings. 

Routine  curetment  of  the  uterus  is  the  rule  in  all  cases 
requiring  abdominal  section  for  pelvic  inflammatory  diseases, 
except  the  streptococcic  cases.  The  uterus  is  dilated,  curetted 
and  then  wiped  out  with  7  per  cent,  tincture  of  iodin  or  pure 
carbolic  acid.  The  acid  application  is  followed  by  one  of 
alcohol  to  the  vagina  (not  uterus)  to  prevent  vaginal  burns. 

Ligature  material  in  all  operations  should   be  number  3 


TUBERCULOSIS    OF    THE    FALLOPIAN  ^TUBES  1 79 

chromic  catgut.  Silk  or  any  permanent  suture  material  should 
be  avoided  as  secondary  abscesses  and  abdominal  sinus  are 
very  common  after  their  use. 

Several  methods  to  combine  pressure  and  heat  as  hemostatics 
and  thus  do  away  with  ligatures  altogether  have  been  devised. 
Most  notable  is  the  Downs  electrothermic  angiotribe,  but  none 
of  these  appliances  give  even  reasonable  safety  from  secondary 
hemorrhage,  and  they  are  not  to  be  recommended. 

VIL  TUBERCULOSIS  OF  THE  FALLOPIAN  TUBES 

Tuberculosis  of  the  tube  is  more  common  than  in  any  other 
portion  of  the  genital  tract.  It  attacks  both  the  mucosa 
(endosalpingitis)  and  the  peritoneal  covering  (perisalpingitis) . 

Cause. — ^(i)  Hematogenous  infection  from  some  distant  focus 
which  may  be  latent,  while  the  tubal  process  is  active.  This 
is  the  usual,  and  apparently  primary,  type.  (2)  Descending 
infection  from  the  peritoneum;  (3)  ascending  infection  from 
the  external  genitalia  (exceedingly  rare). 

Pathology.^ — (i)  Except  in  general  miliary  tuberculosis,  the 
condition  is  always  chronic;  (2)  it  is  always  bilateral;  (3)  the 
mucosa  and  tube  wall  are  infiltrated  with  round  cells,  among 
which  are  many  typical  tubercles,  with  giant  and  epithelioid 
cells;  (4)  the  abdominal  end  closes  early,  so  that  pyosalpinx 
promptly  develops;  (5)  the  peritoneal  coat  is  studded  with  hard 
yellowish  tubercles,  like  millet  seed;  (6)  the  contents  of  the 
tube  are  white,  cheesy  pus  if  the  process  is  purely  tubercular; 
or  creamy  yellow  pus  if  it  is  a  mixed  infection  (as  is  common) ; 
(7)  tubercle  bacilli  can  be  demonstrated  in  section  of  the  tube 
wall.  (8)  The  adhesions  of  tubercular  pus  tubes  are  often  very 
dense,  and  sometimes  absolutely  inoperable — in  contrast  to 
gonorrhea,  which  are  rarely  so.  (9)  Tuberculosis  of  the  tube 
can  exist  in  fetal  life. 

Symptoms  are  like  those  of  any  other  salpingitis.  Tuber- 
cular salpingitis  is  fairly  common  in  young  girls,  so  that  an 
inflammatory  pelvic  mass,  in  a  patient  with  intact  hymen,  may 
safely  be  diagnosed  as  tubercular. 


l8o  DISEASES    OF    THE    FALLOPIAN    TUBES 

Progress  is  slow  and  insidious.  If  it  appears  in  youth,  it  is 
associated  with  general  under-development.  Amenorrhea  is 
common,  and  sterility  is  inevitable. 

Treatment.- — Abdominal  section  with  removal  of  both  tubes 
and  such  other  portion  of  the  genital  organs  as  show  marked 
involvement.  Drainage  of  the  abdomen  is  contra-indicated. 
At  operation  the  mass  of  adhesions  may  be  inextricable,  and 
the  case  abandoned  as  inoperable.  In  such  cases  the  simple 
opening  of  the  abdomen  and  admission  of  air  may,  as  in  tuber- 
cular peritonitis,  effect  extraordinary  cures,  by  spontaneous 
absorption  and  disappearance  of  the  adhesions. 

Operation  is  contra-indicated,  if  there  are  remote  active 
lesions  threatening  the  patient's  life,  or  in  acute  general 
miliary  tuberculosis. 

VIII.  TUMORS  OF  THE  FALLOPIAN  TUBES 

Tumors  are  rare.  They  are  either  benign  or  malignant. 
The  benign  growths  are  fibroma,  fibromyoma  or  adenomyoma; 
they  are  small,  usually  in  the  inner  one- third  of  the  tube,  give 
no  symptoms  and  are  usually  accidentally  found  at  operation. 
Malignant  growths  are  carcinoma,  sarcoma,  chorion-epithe- 
lioma and  endothelioma. 

Primary  carcinoma  of  the  tube  occurs  most  often  after  the 
menopause,  between  fifty  and  sixty.  It  is  originally  in  the 
mucous  membrane  and  is  supposed  to  be  caused  by  pre-existing 
inflammation.  It  is  a  papillary  growth,  and  is  usually  in  the 
outer  third  of  the  tube. 

It  is  also  secondary  to  cancer  of  the  uterus  (fundus)  or 
general  abdominal  carcinomatosis. 

Symptoms  are  those  of  the  pelvic  inflammation  which 
accompany  it.  The  true  diagnosis  is  made  at  operation.  In 
doubtful  cases  a  small  piece  is  excised  and  a  rapid  diagnosis 
made  by  the  freezing  microtome. 

Treatment  is  abdominal  panhysterectomy. 

Recurrence  is  common,  due  to  abdominal  adhesions. 

Cysts  of  Morgagni — small  pedunculated  cysts  hanging  from 


VARICOCELE    OF    THE   PAMPINIFORM    PLEXUS  1 61 

the  fimbriated  extremity  of   the   tube,   have  no   clinical   or 
pathological  significance.     They  are  limited  in  size. 

K.  VARICOCELE  OF  THE  PAMPINIFORM  PLEXUS 

This  is  very  common,  being  associated  with  any  chronic 
congestion  of  the  genital  organs.  It  is  more  common  on  the  left 
side,  and  the  discomfort  is  more  marked,  due  to  the  left  ovarian 
vein  emptying  into  the  renal  at  a  right  angle,  without  a  valve. 


Pig.   70. — Varicocele  of  the  pampiniform  plexus  and  the  placing  of  the  first 
ligature.     (After  B.  C,  Hirst.) 

Symptoms. — (i)  Heavy,  dull  aching  pain  in  the  groin, 
usually  the  left,  worse  on  standing,  worse  at  the  periods,  and 
relieved  by  lying  down.  It  is  aggravated  by  exertion.  The 
symptoms  are  not  distinctive  and  a  definite  diagnosis  cannot  be 
made  by  vaginal  examination.  The  condition  is  usually 
found  coincident  with  other  pelvic  disease. 

Treatment.^ — (i)  Remove  any  cause  of  uterine  congestion 
which  can  be  found.  (2)  Pituitrin  3^^  mil  hypodermically 
every  day  for  ten  doses.  (3)  If  the  veins  are  found,  at  opera- 
tion, to  be  distended,  ligature  and  excision  is  the  only  cure. 


CHAPTER  IX 
DISEASES  OF  THE  OVARY 

GENERAL  ANATOMY  AND  RELATIONS  OF  THE  OVARY 

The  ovary  secretes  ovules  during  the  period  of  the  woman's 
sexual  activity,  from  the  fifteenth  to  the  forty-fifth  year,  on 
the  average.  It  is  an  elliptical  gland,  5  cm.  long,  3  cm.  broad 
and  3^^  cm.  thick  and  weighs  about  8  grams.  It  lies  against 
the  posterior  border  of  the  broad  ligament,  in  a  depression  on 
the  lateral  pelvic  wall  {the  ovarian  fossa)  ^  to  which  it  is  attached 
by  a  reduplication  of  the  peritoneum  of  the  broad  Ugament — 
the  mesovarium — containing  the  blood-vessels,  nerves  and 
lymphatics.  The  ovary  is  the  only  structure  projecting  into 
the  peritoneum  which  has  no  peritoneal  covering. 

Ligaments.^ — From  the  uterine  pole  of  the  ovary  runs  the 
utero-ovarian  ligament;  from  the  tubal  pole  runs  the  infun- 
dibulopelvic  ligament  (a  thin  band  of  connective  tissue  in  the 
upper  margin  of  the  broad  ligament).  To  the  tubal  pole  is 
attached  the  ovarian  fimbria. 

Arteries  are  branches  of  the  ovarian  artery  and  ovarian 
branch  of  the  uterine  artery.  They  enter  the  ovary  at  the 
hilus. 

The  veins  leave  the  ovary  at  the  hilus.  They  empty  into 
the  pampiniform  plexus,  which  in  turn  leaves  the  broad  liga- 
ment as  the  ovarian  vein.  This  empties  into  the  renal  on  the 
left;  into  the  inferior  vena  cava  on  the  right. 

The  lymphatics  leave  the  ovary  with  the  veins  and  empty 
into  the  deep  lumbar  glands. 

The  nerves  are  derived  from  the  plexus  surrounding  the 
ovarian  artery.     They  are  sensory  and  vasomotor. 

Histologic  divisions  are  (i)  the  hilus — where  the  mesovarium 
is  attached  and  where  the  vessels  enter  and  leave  the  ovary; 


GENERAL  ANATOMY  AND  RELATIONS  OF  THE  OVARY    1 83 


(2)  the  o'ophoron — ^the  egg-secreting  portion,  containing  the 
Graafian  folHcles;  (3)  the  paroophoron — ^containing  the  micro- 
scopical remains  of  the  Wolffian  body;  (4)  the  parovarium 
(epoophoron) — in  the  mesovarium,  consisting  of  six  to  twelve 
small  ducts,  like  the  teeth  of  a  comb,  emptying  into  a  common 
duct  (Gartner's  duct)  representing  the  back  of  the  comb. 
Gartner's  duct  runs  parallel  with  the  tube,  and  usually  ends  in 
a  blind  pouch  in  the  broad  ligament.  Occasionally  it  can  be 
traced  through  the  broad  ligament,  uterine  wall,  vaginal  vault 


Oophoron         v      [^ydafld  of 
or  Egg  bearing  porrionj    Mdr^agnl  ok 


Mullerj  duet- 


Fig.   71. — Diagram    of   the   tube,    ovary  and  broad  ligament,  and  their 
structure.     {After  Stewart.) 

and  down  the  anterior  vaginal  wall  as  far  as  the  vulvar 
orifice. 

Development  of  the  Ovary. — The  ovary  is  developed  about 
the  sixth  week  of  fetal  life,  the  genital  glands  appearing  to  the 
median  side  of  Miiller's  ducts  and  the  Wolffian  body.  The 
germinal  epithelial  cells  permeating  the  ovary  are  cut  off  and 
confined  in  connective  tissue  spaces. 

A  primordial  follicle  is  one  of  these  connective-tissue  spaces 
surrounded  by  a  wreath  of  capillaries  and  contains  a  highly 
specialized  cell — the  ovum. 

Descent  of  the  ovary  takes  place  at  the  third  month  of 
fetal  life,  being  drawn  down  by  the  gubernaculum  of  Hunter. 
This  gubernaculum  fuses  in  its  upper  portion  with  the  Miiller- 
ian  ducts  at  their  point  of  union — at  the  fundus  uteri,  and 
finally  remains  as  the  ovarian  and  round  ligaments. 

Graafian  Follicles. — The  chief  function  of  the  ovary  is  the 


184  DISEASES    OF   THE   OVARY 

development  and  ripening  of  Graafian  follicles  and  the  dis- 
charge of  ova.  At  birth  each  ovary  contains  about  30,000 
primordial  follicles,  and  no  new  ones  are  created  after  birth. 
The  follicles  are  all  contained  in  the  oophoron  or  parenchy- 
matous layer  of  the  ovary. 

There  are  three  stages  in  the  maturing  of  the  follicle:  (i)  The 
primordial;  (2)  the  ripening  and  (3)  the  mature  follicle. 
The  primordial  follicle  lies  embedded  in  the  ovarian  stroma, 
and  consists  of  the  ovum  surrounded  by  a  single  layer  of  low 
fiat  epithelium.  When  the  follicle  begins  to  ripen,  the  epi- 
thelial cells  surrounding  it  multiply  into  several  layers,  and 
lie  closely  around  the  ovum.  In  the  mass  of  cells  appears  a 
clear  space,  which  becomes  filled  with  fluid — the  liquor  folliculi, 
and  partly  surrounds  the  ovum.  The  ovum  is  still  surrounded 
by  several  layers  of  epithelial  cells,  which  project  into  the 
clear  space  like  a  peninsula.  These  cells  form  the  discus 
proligerus,  and  the  rest  of  the  epithelium,  around  the  follicle, 
is  called  the  membrana  granulosa.  At  the  same  time  the 
outside  of  the  follicle  is  being  surrounded  by  an  envelope  of 
connective  tissue,  the  theca  folliculi,  which  has  two  layers, 
an  external  and  internal.  The  ovum  itself  is  now  surrounded 
by  a  capsule — the  zona  pellucida,  which  contains  fluid,  so  that 
the  ovum  is  not  in  direct  contact  with  its  capsule.  The  ovum 
is  nourished  through  this  fluid  and  the  liquor  folliculi.  As  the 
follicle  ripens,  it  at  first  retreats  into  the  ovary,  but  later, 
when  fully  ripe  and  distended  with  liquor  folliculi,  it  again 
approaches  the  surface  and  bulges  out  on  it.  At  a  point 
opposite  the  ovum  there  appears  a  pale  translucent  spot — 
the  stigma,  and  through  this  the  follicle  ruptures  and  dis- 
charges its  contents.  The  ovum  is  carried  into  the  tubal  canal 
by  the  current  set  up  by  the  ciliated  epithelium,  or  it  may  be 
discharged  directly  into  the  ampulla. 

Ovulation  should  normally  occur  a  few  days  before  or  syn- 
chronously with  menstruation.  This  rule  is  by  no  means 
constant  and  practically  the  two  processes  can  occur 
independently. 


ABNORMALITIES    AND    DISEASES  1 85 

The  corpus  luteum  begins  to  be  formed  as  soon  as  the  ovum 
is  discharged.  The  empty  follicle  fills  with  blood.  The 
yellow  wrinkled  membrane  surrounding  the  central  blood 
mass  is  derived  from  hypertrophied  cells  of  the  membrana 
granulosa — now  called  lutein  cells^ — and  is  of  connective  tissue 
origin.  This  layer  contains  connective  tissue  and  blood-ves- 
sels. The  regression  of  the  corpus  luteum  takes  about  four 
weeks,  except  for  that  of  pregnancy,  which  lasts  seventy-five 
to  one  hundred  and  twenty  days.  The  yellow  coloring  matter 
is  absorbed,  and  by  hyaline  degeneration  and  shrinking  the 
corpus  albicans  is  formed.  This  white  body  persists  for  a  long 
time,  but  finally  disappears  completely,  leaving  only  a  small 
indentation  on  the  surface  of  the  ovary. 

As  only  a  small  proportion  of  follicles  ever  develop  and 
mature,  the  others  are  absorbed  by  "atresia  of  the  follicle." 

Ovarian  Internal  Secretion. — The  exact  nature  and  its 
source  are  not  known.  Part  comes  from  the  follicle  apparatus, 
which  presumably  controls  the  growth  and  development  of 
the  genitalia;  part  from  the  corpus  luteum  and  probably  con- 
trols menstruation  and  prepares  the  endometrium  for  the 
reception  of  the  fertilized  ovum.  Part  comes  possibly  from 
the  interstitial  portion  of  the  gland,  though  this  is  as  yet 
entirely  theoretical. 

Atrophy  of  the  ovary  is  permanent  after  the  menopause,  and 
to  a  certain  extent  temporary  during  lactation. 

Absence  of  the  ovary  is  seen  only  in  absence  of  the  entire 
genital  system,  or  in  unilateral  development  of  the  uterus — 
uterus  unicornis. 

Accessory  ovary  is  rare;  it  is  not  known  whether  it  is  a 
diverticulum  from  the  normal  ovary  or  an  independent  gland. 

ABNORMALITIES  AND    DISEASES 
I.  Cirrhosis  of  the  Ovary 

Cirrhosis  of  the  ovary  is  physiologic  at  the  menopause,  the 
ovary  becoming  much  smaller,  harder  and  wrinkled.  It  is 
occasionally   seen    during   menstrual   life,    involving    only    a 


1 86  DISEASES    OF    THE    OVARY 

part  of  the  ovary  as  a  rule,  but  at  times  the  whole  gland.  It 
is  common  in  single  women,  past  the  age  of  thirty-five.  Its 
only  symptom  is  dysmenorrhea  persisting  in  spite  of  dilatation 
of  the  cervical  canal.  It  may  require  abdominal  section,  if 
the  pain  is  severe  enough  to  demand  relief,  with  resection  or 
removal  of  the  ovary.  Medical  treatment,  either  general  or  by 
local  application,  is  useless. 

11.  Congestion  of  the  Ovary 

Congestion  of  the  ovary  is  physiological  at  each  menstrual 
period,  during  coitus  and  in  pregnancy.  At  other  times  it 
is  secondary  to  retrodisplacement  of-  the  uterus,  coitus  inter- 
ruptus  or  any  other  cause  of  general  pelvic  congestion.  A 
consequence  of  prolonged  congestion  is  chronic  parenchymatous 
hypertrophy  with  multiple  cysts. 

Ordinarily  the  condition  is  promptly  relieved  by  the  correc- 
tion of  its  cause. 

III.  Cysts  of  the  Ovary 

Classification. — Cysts  of  the  ovary  are  classified  according 
to  the  histologic  division  of  the  ovary  from  which  they  spring; 
or  according  to  their  clinical  importance. 

Histologic  Classification. — i.  Cysts  of  the  Oophoron. — (i) 
Simple  follicular  cysts;  (2)  multiple  follicular  (cystic  ovary); 
(3)  cysts  of  corpus  luteum;  (4)  dermoid. 

.  II.  Cysts  of  the  Paroophoron. — (i)  Cystadenoma  or  glandular 
cysts. 

III.  Cysts  of  Parovarium. — (i)  parovarian. 

Clinical  Classification. — I.  Simple  or  non-proliferating — ^(i) 
Simple  follicular;  (2)  cystic  ovary;  (3)  corpus  luteum. 

II.  Proliferatijtg  Cysts. — (i)  Cystadenoma  or  glandular; 
(2)  parovarian. 

III.  Ovigenous. — (i)  Dermoid;  (2)  teratomata. 

IV.  Degenerations. — (i)  Papillary;   (2)  carcinoma. 
Characteristics  of  Ovarian  Cysts. — I.  Follicular  cysts  may 

be  either  single  or  multiple.  They  are  frequently  a  result 
of  chronic  interstitial  inflammation.     They  are  of  slow  growth, 


ABNORMALITIES    AND   DISEASES  1 87 

of  limited  size  (about  that  of  the  fist) ,  have  a  thin  translucent 
wall  and  most  of  them  are  unilocular.  They  are  intraperi- 
toneal, benign,  and  have  a  pedicle.  The  contained  fluid  is 
clear. 

II.  Corpus  luteum  cysts  are  limited  in  size,  of  slow  growth, 
are  intraperitoneal  and  have  a  pedicle.  The  cyst  wall  on 
section  is  yellow,  and  the  contained  fluid  reddish  and  turbid. 
These  cysts  are  especially  prone  to  intracystic  bleeding.     The 


Fig.  72. — Simple  follicular  cyst  of  the  ovary.     {After  B.  C.  Hirst.) 

bleeding  is  rarely  serious,  and  is  usually  completely  absorbed. 
When  it  is  not,  it  forms  the  so-called  tarry  hematoma  of  the 
ovary,  the  old  blood  being  black  as  tar. 

The  lutein  cysts  associated  with  hydatid  mole  or  chorion- 
epithelioma  are  called  theca-leutin  cysts. 

III.  Cystadenomata  (glandular  cysts;  pseudomucin  cysts) 
are  of  two  kinds;  (i)  pseudomucinous  and  (2)  serous. 

The  pseudomucin  cysts  are  said  to  be  the  commonest  form  of 
ovarian  tumor.  They  are  of  unlimited  size  and  usually  rapid 
growth;  unilateral;  always  multilocular;  the  locules  varying 
widely  in  size,  containing  a  thick  mucoid  substance,  alkaline 
in  reaction,  closely  resembling  true  mucus,  but  differing  in 
that  it  does  not  give  the  mucin  reaction  with  acetic  acid 


1 8s  DISEASES    OF    THE    OVARY 

(hence  pseudomucin).  The  cysts  are  intraperitoneal,  and 
have  a  pedicle.  The  pseudomucin  may  be  of  various  colors, 
due  to  bleeding  or  local  necrosis  in  the  cyst,  varying  from 
clear  glassy  mucus  to  black. 

The  locules  are  lined  with  high  non-ciliated  cylindrical  epithe- 
lium, which  secretes  the  pseudomucin.  These  cysts  rarely 
undergo  papillary  or  malignant  degeneration. 

Serous  cystadenomata  are  often  bilateral,  always  multilocu- 
lar,  though  the  locules  are  fewer.  They  are  intraperitoneal, 
have  a  pedicle  and  contain  a  clear  yellow  serum,  rich  in  albu- 
min, but  without  pseudomucin.  They  nearly  all  show  papil- 
lary proliferation  of  the  lining  epithelium  and  are  very  prone 
to  become  malignant,  and  hence  often  recur  after  operation  as 
local  or  general  peritoneal  carcinomatosis.  Both  pseudomucin 
and  serous  cystadenomata  originate  from  the  germinal  epi- 
thelium, but  their  cause  is  not  known. 

IV.  Parovarian  cysts  arise  from  an  abnormal  section  of  the 
lining  epithelium  of  the  longitudinal  duct.  They  are  therefore 
retention  cysts  and  not  really  proliferating  growths.  They 
are  unilocular,  and  contain  an  opalescent  serum.  They 
are  of  rapid  growth,  reach  a  large  size,  extraperitoneal  between 
the  layers  of  the  broad  ligament.  They  rarely  have  a  pedicle. 
The  Fallopian  tube  is  stretched  out  over  the  surface  of  the  cyst. 
The  ovary  is  not  destroyed,  but  is  attached  to  the  surface  of  the 
tumor.  This  cyst  has  two  coverings:  the  peritoneum  of  the 
broad  ligament  and  its  own  wall.  The  lining  epithelium  is 
ciliated.  Papillary  degeneration  is  very  rare  and  rarely  if 
ever  do  they  become  malignant. 

V.  Dermoid  cysts  constitute  about  lo  per  cent,  of  all  ovarian 
tumors.  They  are  of  slow  growth,  limited  size  (that  of  the 
clenched  fist)  are  intraperitoneal  and  have  a  pedicle.  They  are 
prone  to  become  adherent,  and  cause  more  pain  than  any  other 
cyst  of  moderate  size.  They  are  unilocular  and  contain  all 
kinds  of  fetal  structures — sebaceous  matter,  hair,  and  bone  in 
that  order  of  frequency.  No  fetal  membranes  have  ever  been 
found. 


ABNORMALITIES    AND   DISEASES  1 89 

Dermoids  rarely  become  malignant,  though  malignant  degen- 
eration of  their  epithelial  contents  is  not  rare.  They  are  often 
associated  with  pseudomucin  cysts,  are  not  infrequently 
bilateral.  They  have  long  pedicles,  and  are  therefore  espe- 
cially prone  to  twist  on  their  pedicles.  Their  contents  are  very 
putrescible  and  if  ruptured  usually  cause  peritonitis. 

Teratomata  are  the  rarest  of  ovarian  growths.  They  are  like 
dermoids,  in  the  fetal  structures  present,  but  are  essentially 
malignant  (sarcoma).  They  grow  rapidly,  reach  large  size 
and  give  early  and  free  metastasis.  Only  about  fifty  cases  are 
on  record. 

Certain  teratomata,  containing  a  preponderance  of  thyroid 
tissue,  are  known  by  the  term  "struma  ovarii." 

There  are  two  theories  for  the  origin  of  dermoid  cysts:  (i) 
Fetal  inclusion;  (2)  parthenogenesis — from  imperfect  segmenta- 
tion and  development  of  the  true  germ  cell,  or,  as  has  been  lately 
advanced,  from  a  blastomere — -separated  from  the  true  cell. 

The  pedicle  of  an  ovarian  cyst  is  composed  of  the  ovarian 
ligament,  the  infundibulopelvic  ligament,  the  free  edge  of  the 
broad  ligament,  the  tube  and  the  utero-ovarian  anastomosis 
of  vessels.  It  is  not  possible,  as  a  rule  to  tie  off  only  the  meso- 
varium,  which  should  be  the  true  pedicle.  All  the  above- 
mentioned  structures  are  included  in  the  ligature. 

Rate  of  growth  of  cysts  is  usually  considerably  more  rapid 
than  a  solid  tumor,  such  as  a  fibroid,  because  being  a  secreting 
tumor,  it  can  form  fluid  faster  than  a  solid  tumor  can  form  new 
cells.  Like  a  fibroid,  the  presence  of  ascites  usually  means 
malignancy  or  papillary  degeneration. 

Sym.ptoms  naturally  differ,  with  the  type  of  cyst. 

Symptoms  of  Simple  Follicular,  Cystic  Ovary  and  Corpus 
Luteum  Cysts. — These  depend  to  a  great  extent  upon  the  size 
and  weight  of  the  cyst.  If  uncomplicated,  they  are  often 
unnoticed,  as  tension  on  the  ovarian  substance  by  the  growing 
cyst  does  not  cause  pain.  Very  often  these  cysts  are  first 
diagnosed  by  a  vaginal  examination  made  for  other  reasons. 
When  symptoms  are  present  they  are  as  follows: 


I  go  DISEASES    OF    THE    OVARY 

(i)  Moderate  pelvic  pain,  sometimes  that  of  subacute 
salpingitis;  (2)  pressure  on  bladder  and  rectum;  (3)  men- 
strual irregularity,  usually  scanty,  infrequent  flow;  (4)  sense 
of  weight  in  pelvis  and  backache;  these  usually  only  when  the 
cysfis  adherent. 

Diagnosis  is  made  by  bimanual  examination,  when  the 
globular,  cystic  tumor  can  be  felt,  often  displacing  the 
uterus  to  one  side  and  forward. 

No  diagnosis  of  ovarian  cyst  should  ever  he  made,  until  the 
bladder  is  known  to  he  empty. 

Symptoms  of  Glandular  Cysts  (Adenocystomata). — (i) 
Rapidly  increasing  size  of  the  abdomen;  (2)  menstrual  ir- 
regularity, usually  amenorrhea;  (3)  emaciation  (facies  ovari- 
ana);  (4)  irregular  resistance  of  the  abdominal  wall,  on  pal- 
pation, due  to  large  locules  and  areas  of  greater  density; 
(5)  if  the  growth  is  intraligamentary  and  papillary,  menor- 
rhagia  and  ascites  are  usually  present;  (6)  pressure  symptoms 
on  bowel  and  bladder  appear  early,  and  are  most  severe  in 
intraligamentary  growths;  (7)  edema  of  both  legs  (a  late 
symptom  due  to  pressure). 

Diagnosis  of  glandular  cysts  is  made  by  the  above  symptoms, 
and  by  bimanual  examination,  which  shows  the  uetrus  pressed 
far  forward  and  to  one  side,  and  the  pelvis  blocked  by  a  cystic 
mass  evidently  continuous  with  the  abdominal  mass. 

Differential  diagnosis  between  pseudomucin  and  serous 
cystadenomata  is  made  only  at  operation. 

Symptoms  of  parovarian  cysts  are  the  same  as  the  glandular. 
The  rate  of  growth  is  slower,  they  are  usually  intraligamentary 
and  therefore  pressure  pain  is  a  more  prominent  symptom,  but 
clinically  the  'diagnosis  is  made  only  at  operation. 

Symptoms  of  dermoid  cysts  are  the  same  as  those  of  the 
simple  cysts,  except  that  pain  is  a  prominent  one.  They  are 
the  commonest  ovarian  tumors  in  young  subjects,  but  the 
actual  diagnosis  is  made  at  operation.  The  cyst  wall  is  white, 
with  marked  adhesions  and  often  red  blotches,  in  contrast 
to  the  smooth  shining  bluish  wall  of  the  simple  cyst. 


ABNORMALITIES    AND   DISEASES 


191 


Symptoms  of  Teratomata. — These  are  solid  tumors,  with 
areas  of  cystic  degeneration,  reach  a  large  size,  grow  very 
rapidly  and  are  associated  with  ascites. 

Differential  Diagnosis  of  Ovarian  Cysts. — i.  Pregnancy 
may  be  closely  simulated  in  appearance  by  an  ovarian  cyst, 
but  the  absence  of  confirmatory  signs  of  pregnancy  by  vaginal 
examination;  the  absence  of  fetal  movements  and  heart  sounds; 
the  absence  of  a  shadow  of  the  fetal  skeleton  on  an  a;-ray  plate; 
the  small  hard  uterus  pushed  foward  or  backward  and  to  one 
side  should  make  the  diagnosis  clear. 


Pig.  73. — The  outline  of  the  abdomen  in  a  case  of  large  ovarian 
cyst.  The  outline  of  an  overdistended  bladder  is  very  similar.  {After 
Cross  en.) 

2.  Full  bladder  may  be  at  once  diagnosed  by  catheterization, 
a  precaution  that  should  always  be  taken  in  any  case  of 
supposed  cystic  abdominal  tumor. 

3.  Fibroid  tumor  is  hard,  nodular,  bold  in  its  outlines,  usually 
with  a  history  of  menorrhagia;  the  uterus  forms  part  of 
the  growth  and  the  cervix  moves  in  unison  with  the 
abdominal  mass.  A  dense  firm  intraligamentary  cyst  cannot 
be  differentiated,  as  a  rule. 

4.  Ascites  does  not  displace  the  uterus;  the  contour  of  the 
abdomen,  unless  the  fluid  is  encysted,  changes  as  the  patient 
changes  her  position;  no  cystic  mass  can  be  felt  by  vaginal 


192 


DISEASES    OF    THE    OVARY 


examination.     Encysted  ascites    may    so  closely  simulate  an 
ovarian  cyst  as  often  to  be  indistinguishable  from  it. 

Abdominal  fat  can  easily  be  differentiated  by  bimanual 
examination;  tympanites  by  percussion  and  bimanual  ex- 
amination. Tumors  of  the  kidney  are  rarely  large  enough  to 
be  mistaken  for  ovarian  cysts;  they  do  not  extend  low  enough 
to  be  palpated  through  the  posterior  vaginal  vault,  and  they 
cause  bulging  in  the  triangular  space  of  the  costovertebral 
angle,  when  the  patient  is  erect. 


Pig.   74. — Parovarian    cyst,    showing    the    great    elongation    of  the  Fal- 
lopian tube.      {After  Graves.) 


Treatment  of  an  ovarian  cyst  is  operative.  Palliative 
treatment  is  not  advisable,  because  of  the  ever-present  danger 
of  twist  on  the  pedicle.  Medical  treatment,  of  course  is 
useless. 

Technic  of  operation  for  simple,  corpus  luteum  and  dermoid 
cysts: 

1.  Usual  median  abdominal  incision. 

2.  The  cyst  is  freed  from  any  adhesions  and  dehvered 
through  the  wound.     If  there  is  any  suspicion  that  the  cyst 


ABNORMALITIES    AND    DISEASES  I93 

is  dermoid,  it  should  be  delivered  unruptured.     In  the  others, 
rupture  of  the  cyst  in  delivery  makes  no  difference. 

3.  The  mesovarium  is  transfixed  by  a  pedicle  needle  carrying 
a  number  3  chromic  catgut  ligature,  which  is  then  tied  down 
around  the  pedicle  formed  by  the  tense  mesovarium,  several 
encircling  ties  being  made. 

4.  The  ligature  is  guarded  by  hemostats  clamped  above  it 
and  the  cyst  removed  with  scissors. 

5.  The  other  ovary  is  always  inspected,  as  dermoids 
particularly  are  often  bilateral. 

6.  The  abdomen  is  closed  as  usual. 

If  a  dermoid  is  ruptured  during  removal,  the  sebaceous 
contents  must  be  sponged  out  of  the  abdomen  with  the 
greatest  care.  Although  they  are  sterile,  they  are  extra- 
ordinarily putrescible  and  fatal  peritonitis  may  follow  neglect 
of  the  precaution. 

Technicjor  cystadenomata,  or  parovarian  cysts  with  a  pedicle: 

1.  The  abdomen  is  opened  in  the  usual  way,  the  peri- 
toneum being  first  opened  near  the  umbilicus,  as  the  bladder 
is  often  carried  high  up. 

2.  The  operator's  hand  is  inserted  in  the  abdomen  and  all 
adhesions  are  freed. 

3.  As  long  as  the  cyst  wall  is  blue  in  color  and  free  from 
adhesions,  it  may  be  puctured  with  impunity. 

4.  The  cyst  wall  is  punctured  by  a  large  cannula,  with  rubber 
tube  attached,  and  the  main  locule  drained  into  a  bucket  or 
basin,  at  the  side  of  the  table. 

5.  The  cyst  wall  is  caught  with  clamps  and  pulled  out  of  the 
wound,  as  it  collapses.  In  this  way  a  huge  cyst  may  be 
brought  out  through  a  moderate  incision. 

6.  The  cannula  is  removed,  as  soon  as  the  cyst  is  delivered 
and  the  hole  in  the  cyst  closed  by  a  clamp. 

7.  The  pedicle  is  tied  off,  including  the  tube,  with  number  3 
chromic  catgut  and  the  cyst  removed. 

8.  The  broad  raw  pedicle  is  sewed  over  with  number  i 
chromic  catgut,  to  minimize  the  danger  of  adhesions. 


194        .  DISEASES   OF   THE   OVARY 

9.  The  other  ovary  is  inspected.  In  serous  cystadenomata 
with  papillary  degeneration,  both  ovaries  are  better  removed, 
as  recurrence  is  almost  certain  if  one  is  left. 

10.  The  uterus  is  suspended,  as  otherwise  the  weight  of  the 
pedicle  may  pull  it  backward  and  cause  adherent  retroversion . 

11.  The  abdomen  is  closed  as  usual. 

Technic  for  intraligamentary  cysts,  without  pedicle: 

1.  Median  abdominal  incision. 

2.  If  very  large,  the  cyst  is  tapped  as  described  above. 
If  small,  this  is  unnecessary. 

3.  The  ovarian  artery  in  the  outer  edge  of  the  broad  ligament 
is  tied  in  two  places  and  cut  between. 

4.  The  broad  ligament  is  spht  across  its  anterior  face. 

5.  The  cyst  wall  is  sheUed  out  (easily,  if  not  adherent) 
from  its  bed  in  the  broad  hgament.  Close  watch  must  be 
kept  for  the  ureter,  which  is  often  displaced.  It  can  be  peeled 
off  the  cyst  wall  and  thus  saved  from  injury. 

6.  The  bed  of  the  cyst  is  inspected  for  bleeding  vessels, 
usually  very  few,  which  are  tied.  If  there  is  profuse  general 
oozing  (in  inflamed  adherent  cysts  only)  the  cavity  of  the 
broad  Hgament  is  packed  with  gauze  and  the  end  carried 
down  into  the  vagina,  through  an  opening  in  the  posterior 
vault. 

7.  The  cut  in  the  broad  ligament  is  repaired  and  the  ab- 
domen closed  as  usual. 

8.  If  gauze  packing  is  used,  it  is  removed  in  forty-eight 
hours. 

Tapping  of  large  cysts,  either  through  the  abdominal  wall 
or  posterior  vaginal  vault,  is  objectionable. 

Its  fancied  advantages  are:  (i)  Reduction  in  size  of  the  cyst 
(temporary  only,  as  it  rapidly  refills),  (2)  prevention  of  shock 
at  operation  for  removal,  if  done  two  or  three  days  previously 
(fallacious). 

Objections. — (i)  Rapid  refilHng  of  the  cyst;  (2)  implantation 
metastasis;  (3)  hemorrhage,  if  a  large  vein  be  punctured;  (4) 
infection;  (5)  adhesions,  making  subsequent  operation  more 


ABNORMALITIES    AND   DISEASES 


195 


difScult;  (6)  danger  of  puncturing  a  dermoid, with  consequent 
peritonitis. 

Tapping  will  not  cause  permanent  disappearance  of  a  cyst, 
as  the  small  puncture  closes  promptly  and  the  cyst  refills. 
If  it  is  done,  the  cannula  must  be  of  large  caliber,  as  the  thick 
pseudomucin  will  not  run  out  through  a  small  one. 

Marsupialization  of  a  cyst  is  required  when:  (i)  At  operation 
the  cyst  wall  is  too  densely  adherent  for  complete  removal; 
(2)  in  virulently  infected  cysts.     It  consists  in  securing  the 


Fig.   75. — Ovarian  cyst,  twisted  on  its  pedicle.     The  cyst  wall  is  very  dark 
purple,  almost  black.     {After  Graves.) 


fibrous  cyst  wall  to  the  edges  of  the  abdominal  incision,  after 
opening  the  cyst  and  dissecting  out  its  secreting  glandular 
layer  as  far  as  possible.  The  cavity  is  packed  with  gauze, 
renewed  daily  until  granulation  obliterates  it.  The  method 
is  to  be  avoided  whenever  possible,  as  convalescence  is  exceed- 
ingly prolonged. 

Accidents  to  Cysts. — (i)  Twist  on  the  pedicle;  (2)  rupture; 
(3)  intracystic  hemorrhage. 

(i)  Twist  on  the  pedicle  is  an  ever-present  danger.     The 


196  DISEASES    OF   THE    OVARY 

pedicle  of  every  ovarian  cyst,  as  it  grows  out  of  the  pelvis,  is 
partly  twisted  into  a  spiral,  the  turn  being  to  the  side  from 
which  the  tumor  sprang;  right-sided  cysts  twist  to  the  right, 
and  vice  versa.  As  a  result  of  pressure  of  the  intestines,  sudden 
exertion,  relaxation  of  the  abdominal  walls,  or  often  without 
obvious  cause,  the  cyst  may  twist  from  one  to  seven  complete 
turns.  Moderate  size  tumors  are  more  likely  to  twist  than 
large  ones,  dermoids  are  especially  prone  to  twist,  and  the 
accident  is  very  common  after  childbirth.  As  a  result  of  the 
twist,  the  circulation  is  interfered  with  or  entirely  cut  off, 
the  tumor  becomes  bluish  black.  It  usually  increases  in  size 
suddenly,  and  may  rupture.  If  the  blood  supply  is  completely 
cut  off,  it  becomes  gangrenous. 

Symptoms. — (i)  Sudden  severe  pain;  (2)  shock;  (3)  fever 
(101-102°);  (4)  rapid  pulse  (130-150);  (5)  intense  abdominal 
tenderness  (due  to  non-infectious  peritonitis);  (6)  if  the 
cyst  has  ruptured,  collapse. 

Treatment. — Immediate  operation,  and  removal  of  the  cyst, 
as  described  in  the  treatment  of  simple  cysts.  Care  should  be 
taken  not  to  rupture  the  cyst  in  delivering  it,  and  many  light 
adhesions  will  be  found. 

Thrombosis  of  the  pelvic  veins  in  the  broad  Kgament  is  a 
frequent  complication  and  influences  the  prognosis,  due  to  the 
danger  of  embolus.  Delayed  operation  is  not  advisable,  as 
the  cyst  once  twisted  stays  so,  and  the  patient  may  at  any 
time  become  septic. 

(2)  Rupture  of  a  Cyst. — The  consequences  depend  entirely 
upon  the  nature  of  the  contents,  but  as  a  rule  it  is  not  a  danger- 
ous accident. 

Causes. — (i)  Trauma — such  as  a  fall  or  kick;  (2)  violent 
abdominal  pressure;  (3)  pressure  in  labor;  (4)  bimanual  exami- 
nation; (5)  rapid  increase  in  size;  (6)  necrosis  or  degeneration 
of  the  cyst  wall. 

The  simple  folhcular  and  parovarian  cysts  are  the  most 
likely  to  rupture. 

Symptoms. — In  the  case  of  a  small  follicular  cyst  there  are 


ABNORMALITIES    AND   DISEASES  I97 

usually  no  symptoms  whatever.  The  cyst,  during  a  bimanual 
examination,  is  simply  felt  to  disappear. 

The  symptoms  of  rupture  of  a  large  cyst  are:  (i)  Sudden 
sharp  pain;  (2)  change  in  contour  of  abdomen;  (3)  moderate 
shock;  (4)  rarely  symptoms  of  internal  hemorrhage;  (5)  in 
dermoids,  plastic  peritonitis;  (6)  a  remote  consequence  is  total 
prolapse  of  the  uterus  and  inversion  of  the  vagina,  due  to  the 
weight  of  the  contents.  If  a  dermoid  ruptures,  the  contents 
cause  a  plastic  peritonitis,  with  considerable  fever  and  abdom- 
inal pain.  When  such  a  case  is  operated  upon,  there  is  consider- 
able difficulty  in  cleansing  the  peritoneum,  and  a  fatal  peritonitis 
may  result  from  putrefaction  of  portions  impossible  to  remove. 

The  rupture  of  a  pseudomucin  or  particularly  a  serous  cyst- 
adenoma  is  likely  to  be  followed  by  implantation  metastasis 
of  the  epithelial  elements  on  all  portions  of  the  parietal 
and  visceral  peritoneum  {pseudomyxoma  peritonei). 

Prognosis. — A  ruptured  cyst  does  not  necessarily  demand 
immediate  operation.  Small  follicular  cysts  and  more  rarely 
parovarian  cysts  may  be  spontaneously  cured  in  this  way. 
The  opening  in  the  cyst  usually  closes,  and  the  cyst  refills. 
Cystadenomata  and  dermoids  require  prompt  operation. 

Treatment. — (i)  If  the  cyst  is  a  small  one,  which  ruptures 
during  a  bimanual  examination,  and  there  are  no  immediate 
symptoms,  wait.  (2)  If  the  cyst  is  large,  immediate  operation, 
being  careful  to  cleanse  the  peritoneum  and  remove  all  visible 
traces  of  the  cyst  contents,  to  prevent  implantation  meta- 
stasis. (3)  In  a  dermoid  cyst,  unless  sure  that  all  particles 
have  been  removed,  it  is  safer  to  drain. 

(3)  Intracystic  hemorrhage  is  usually  a  consequence  of  twist 
on  the  pedicle.  It  is  often  profuse  enough  to  cause  severe 
shock,  and  may  be  fatal.  It  is  rarely  seen  at  other  times, 
but  may  be  due  to:  (i)  tapping;  (2)  spontaneous  rupture  of  a 
vein.  The  symptoms  are  the  same  as  those  of  severe  internal 
hemorrhage  from  any  cause,  and  the  treatment  is  immediate 
operation,  removal  of  the  cyst  and  stimulation,  with  either 
intravenous  injection  of  salt  solution  or  transfusion. 


iqS 


Dis:EASES    OF   THE    OVARY 


Degenerations  of  Ovarian  Cysts. — (i)  Papillary  degeneration 
can  occur  in  any  type  of  ovarian  cyst,  but  is  rare  except  in  the 
serous  cystadenomata.  These  latter  almost  invariably  show  it. 
The  papillary  masses  are  found  in  the  cyst,  and  on  its  surface 
(by  the  rupture  of  a  locule  overfilled  with  papillary  growth). 

They  give  implantation  metastasis  everywhere  throughout 
the  abdomen.  There  is  usually  associated  ascites,  so  that  an 
ovarian  cyst  with  ascites  may  safely  be  assumed  to  be  papillary 
or  malignant.  Papillary  degeneration  is  essentially  malignant, 
and  recurrences  (inoperable)  after  removal  are  the  rule.  If 
the  papillary  growth  is  extensive,  the  operation  is  likely  to  be 
complicated  by  excessive  bleeding. 


Pig.  76. — Bilateral  serous  cystadenoma  of  the  ovary,  with  papillary 
degeneration.  The  cyst  on  the  right  has  ruptured  and  turned  inside  out. 
{After  Penrose.) 

(2)  Carcinomatous  degeneration  is  usually  a  result  of  primary 
papillary  degeneration,  and  associated  with  ascites.  It  has 
a  tendency  to  give  early  metastasis  into  the  retroperitoneal 
tissues  of  the  broad  ligament  and  also  by  inplantation  meta- 
stasis over  the  peritoneum.  Cachexia  and  wasting  are  marked 
and  rapid.  These  patients  do  not  stand  operation  well,  and 
if  the  involvement  of  neighboring  structures  is  extensive, 
complete  removal  is  better  not  attempted.  Even  in  appar- 
ently uncomplicated  cases,  recurrence  is  the  rule  and  prognosis 


ABNORMALITIES    AND   DISEASES  1 99 

for  cure  is  very  bad.    The  most  favorable  cases  are  those  where 
the  malignant  process  is  confined  to  an  unruptured  cyst. 

(3)  Infection  and  suppuration  occurs:  (i)  As  a  result  of  infec- 
tion after  labor;  (2)  as  a  result  of  twisted  pedicle;  (3)  by 
infection  from  bowel  adhesions;  (4)  by  tapping.  Any  cyst  may 
become  infected,  but  dermoids  are  the  commonest. 

Symptoms  are  those  of  acute  infection  from  any  cause:  fever, 
rapid  pulse,  leukocytosis,  chills,  etc.- — plus  the  cystic  abdominal 
mass. 

Treatment. — -Early  operation  and  removal  of  the  cyst  without 
opening  it.  The  septic  intoxication  is  often  profound  and 
delay  is  dangerous.  Adhesions  are  found  early  and  rupture 
into  the  bowel,  bladder,  vagina  or  peritoneum  is  not  uncommon. 
The  latter  is  aways  fatal.  In  other  cases  the  drainage  is 
only  partial  and  operation  is  urgently  required.  Drainage  is 
required,  especially  in  those  cases  where  there  has  been  rupture 
of  the  cyst  into  the  bladder,  bowel  or  vagina.  The  fistula 
should  be  closed,  but  will  usually  reopen.  In  desperate  cases, 
where  no  prolonged  operation  can  be  attempted,  marsupial- 
ization of  the  cyst  to  a  small  abdominal  incision  and  its  drain- 
age is  advisable.     Later  the  cyst  can  be  removed. 

(4)  Implantation  metastases  are  the  result  of:  (i)  Papillary 
degeneration;  (2)  malignant  degeneration;  (3)  rupture  of  a  cyst; 
(4)  spilling  the  contents  in  the  peritoneum  during  operation. 
They  occur  all  over  the  visceral  and  parietal  peritoneum  even 
in  distant  portions  of  the  abdominal  cavity.  They  are  com- 
posed of  the  epithelial  elements  of  the  cyst  and  secrete  pseudo- 
mucin,  until  the  whole  cavity  becomes  filled  with  semisohd 
gelatinous  masses  that  cannot  be  removed.  This  condition 
is  called  pseudomyxoma  peritonei  and  while  in  itself  benign,  it 
causes  a  form  of  chronic  peritonitis  which  eventually  kills  the 
patient.  Life  may  be  prolonged  by  repeated  laparotomies 
and  removal  of  as  much  of  the  growth  as  possible,  and  rarely 
it  happens  that  a  single  operation  effects  a  cure.  As  a  rule 
the  prognosis  is  bad. 

Prognosis  of  Ovarian  Cysts.— If  papillary  degeneration  be 


200  DISEASES    OF    THE    OVARY 

included  in  malignancy,  about  25  per  cent,  of  cysts  are  malig- 
nant. In  uncomplicated  cysts,  operation  is  simple  and  safe. 
In  intraligamentary  cysts  it  may  be  a  most  formidable  pro- 
cedure. The  complications  with  the  greatest  immediate 
danger  are  twist  on  the  pedicle  and  suppuration.  The  prog- 
nosis of  malignant  growths  is  bad,  and  the  recurrence  is  usu- 
ally rapid  and  always  inoperable.  The  least  dangerous  of  all 
cysts  are  the  simple  follicular  and  parovarian.  Serous  cysta- 
denomata  are  constantly  bilateral,  the  others  only  occasionally. 

IV.  Displacements  of  the  Ovary 

Displacements  of  the  ovary  occur  through  a  rather  limited 
range.  It  may  become  adherent,  during  the  puerperium  while 
the  uterus  is  large,  and  remain  fixed  high  out  of  the  pelvis. 
Congenitally  the  ovary  may  fail  to  descend,  but  remain  at 
the  embryonic  level,  near  the  kidney.  Clinically,  the  chief 
displacement  is  prolapse  of  the  ovary  into  Douglas'  pouch. 

Causes. — (i)  Violent  exercise  or  traumatism;  (2)  secondary 
to  retroversion  of  the  uterus;  (3)  increase  in  size  and  weight 
of  the  ovary;  (4)  tumors. 

It  is  more  common  in  nulliparous  women  and  is  due  to  elonga- 
tion of  the  infundibulopelvic  ligament.  It  is  either  (i) 
primary  or  (2)  secondary  (to  retroversion  of  the  uterus)  and, 
if  primary,  is  commonest  on  the  left  side. 

Symptoms. — (i)  Very  often  no  symptoms  whatever,  being 
discovered  accidentally  during  an  examination  for  other  con- 
ditions; (2)  pelvic  pain,  worse  when  on  feet;  (3)  pain  worse 
before  and  just  after  menstruation;  (4)  worse  on  coitus  and 
defecation;  (5)  occasionally  nausea  and  sickening  pain,  par- 
ticularly after  any  jar  or  jolt. 

Diagnosis. — The  ovary  can  be  felt  best  by  rectal  examina- 
tion, as  a  round,  tense  and  elastic  body,  lying  in  Douglas' 
pouch,  below  the  uterosacral  ligaments.  Any  doubt  as  to 
its  character  can  be  settled  by  the  distinctive  sickening  pain 
caused  by  pressure  on  it. 


ABNORMALITIES    AND   DISEASES  20I 

Treatment  is  either  palliative  or  operative.  In  patients 
without  symptoms,  treatment  is  of  course  unnecessary. 

Palliative  Treatment. — (i)  Digital  reposition  of  the  ovary 
to  as  high  a  level  as  possible,  by  pressure  through  the  rectum 
or  vaginal  vaults;  (2)  knee-chest  posture  for  one-half  hour  three 
times  daily;  (3)  pessaries  and  tampons  are  useless.  Pallia- 
tive treatment  is  of  use  only  when  the  ovary  is  not  adherent. 

Operative  Treatment. — (i)  Through  a  median  abdominal 
incision  the  ovary  is  brought  up  and  inspected.  (2)  If  any  por- 
tion is  diseased  or  cystic,  that  portion  can  be  resected  by  a 
V-shaped  excision,  and  the  wound  closed  with  interrupted 
(never  continuous)  stitches  of  number  i  chromic  catgut,  taking 
a  deep  bite  of  the  ovarian  tissue  and  tied  gently  so  as  not  to 
cut.  (3)  The  infundibulopelvic  ligament  is  caught  with  a 
hemostat  near  the  ovary  and  again  at  the  pelvic  wall,  under 
the  sigmoid.  (4)  With  a  curved  intestinal  needle,  armed  with 
fine  linen  thread,  the  ligament  is  picked  up  at  three  or 
four  places  about  one-half  inch  apart,  using  the  stitch  as  a 
continuous  one.  (5)  When  the  stitch  is  tied,  the  ligament  is  so 
shortened  as  to  lift  the  ovary  to  the  level  of  the  cornu  of  the 
uterus.  (6)  If  the  ovary  is  grossly  diseased,  it  must  be  re- 
moved and  not  suspended.     (7)  The  abdomen  is  closed. 

Ovarian  prolapse,  secondary  to  retroversion  of  the  uterus 
usually  disappears  on  correction  of  the  retroversion.  If  not, 
the  ligament  can  be  shortened  in  addition. 

V.  Inflammation  (Oophoritis)  and  Abscess 

Inflammation  of  the  ovary  is  either  (i)  acute  or  (2)  chronic. 

Acute  inflammation  is  due  to:  (i)  Streptococcus  pyogenes 
after  miscarriage  or  labor  at  term;  (2)  gonorrhea;  (3)  colon 
bacillus;  (4)  pneumococcus;  (5)  typhoid  bacillus.  This  is 
approximately  the  order  of  frequency  of  the  most  common 
infections,  puerperal  streptococcic  being  overwhelmingly 
the  most  common.  Gonorrheal  ovarian  abscess  is  almost 
invariably  secondary  to  tubal  abscess.  Except  in  gonorrheal 
infection,  the  bacteria  enter  the  ovary  through  the  lymphatics 


202  DISEASES    OF    THE    OVARY 

and  blood-vessels  at  the  hilus.  Gonorrhea  invades  the  ovary 
from  the  lumen  of  the  tube,  through  a  recently  ruptured 
Graafian  follicle. 

Symptoms  are  those  of  acute  pelvic  inflammation  and  cannot 
be  diagnosed,  except  at  operation,  from  acute  tubal  inflam- 
mation. This  latter  is  the  commoner  condition  and  operation, 
if  needed,  is  based  upon  this  diagnosis,  (i)  Acute  abdominal 
pain;  (2)  fever;  (3)  rapid  pulse;  (4)  leukocytosis  (18,000 
to  24,000);  decubitus  of  peritonitis;  (6)  by  bimanual  examina- 
tion, a  very  sensitive  pelvic  mass,  behind  the  uterus.  An 
acutely  inflamed  ovary  is  much  more  painful  than  an  acutely 
inflamed  tube,  which  fact  may  aid  in  diagnosis. 

Treatment. — As  many  cases  do  not  reach  the  suppurative 
stage,  palliative  treatment  is  advisable,  by:  (i)  rest  in  bed; 
(2)  milk  or  liquid  diet;  (3)  ice  bag  or  hot  flaxseed  poultice  to 
lower  abdomen;  (4)  hot  vaginal  douches,  i2o°F.,  four  times  a 
day;  (5)  moderate  laxatives. 

Under  this  treatment  the  acute  stage  may  completely 
subside,  and  spontaneous  recovery  occur.  There  are  often 
dense  adhesions  formed,  however,  which  necessitate  secondary 
operation,  for  relief  of  pain,  especially  at  the  periods.  If 
the  acute  symptoms  do  not  subside  within  three  days,  or 
if  there  .is  steady  increase  in  leukocytes  and  fever,  operation  is 
usually  required.  The  affected  ovary  and  tube  are  removed, 
as  described  in  the  operative  treatment  of  salpingitis.  In 
all  except  the  gonorrheal  or  tubercular  variety,  drainage  is 
required. 

Prognosis. — In  all  except  the  streptococcic  variety,  prog- 
nosis is  good.  A  streptococcic  ovarian  abscess  is  the  most 
virulent  of  all  the  localizations  of  septic  infection,  drainage  is 
absolutely  necessary,  and  in  spite  of  this,  the  mortality  from 
peritonitis  is  high. 

Chronic  oophoritis  is  secondary  to  salpingitis,  or  any  other 
chronic  inflammatory  process  in  the  pelvic  cavity,  or  it  persists 
after  an  acute  attack,  without  abscess  formation. 

Pathology. — (i)  The  whole  ovary  is  enlarged,  firm  and  heavy; 


ABNORMALITIES    AND   DISEASES  203 

(2)  hyperplasia  of  the  interstitial  connective  tissue;  (3)  many 
follicle  retention  cysts;  (4)  few  corpora  lutea,  but  many  corpora 
fibrosa;  (5)  many  extensive  and  dense  adhesions;  (6)  as  a  late 
stage,  great  shrinkage  of  the  ovary,  with  wrinkling  of  its 
surface  (cirrhosis). 

Symptoms. — -(i)  Pain  low  down  in  the  groin,  worse  just 
before  and  after  menstruation;  (2)  pain  on  defecation,  coitus 
or  any  sudden  jar  or  jolt;  (3)  menorrhagia,  with  a  tendency  to 
become  scanty  in  the  later  stages;  (4)  intermenstrual  pain; 
(5)  profound  and  varied  neurosis. 

The  pain  in  these  cases  is  due  to  peritoneal  adhesions,  and 
not  to  the  ovary  itself.  Hence  "ovarian  neuralgia"  is  a 
misnomer. 

Diagnosis. — (i)  By  bimanual  examination  the  ovary  is  felt 
enlarged,  fixed  by  adhesions  and  very  tender  to  palpation; 
(2)  it  is  often  impossible  to  differentiate  from  salpingitis, 
except  by  the  much  greater  pain  of  oophoritis. 

Treatment. — -(i)  Palliative  consists  in  removing  any  cause 
of  chronic  pelvic  congestion,  if  one  can  be  found;  (2)  hot 
vaginal  douching;  (3)  boroglycerid  tampons;  (4)  application 
of  tincture  of  iodin  to  the  vaginal  vaults. 

Palliative  treatment  is  at  best  of  very  doubtful  value,  and 
of  no  value  at  all  if  there  is  much  actual  disease  of  the  ovary. 

Operative  Treatment. — Indications:  (i)  Excessive  pain;  (2) 
patients  past  thirty-five  years  of  age;  (3)  long-standing  dis- 
ability; (4)  degree  of  incapacity  of  the  patient;  (5)  women 
of  the  working  class.  The  operation  should  be  as  conservative 
as  possible.  It  is  frequently  possible  to  break  up  adhesions 
and,  if  the  ovary  is  not  grossly  diseased,  to  suspend  it  as 
described  in  prolapse  of  the  ovary.  Multiple  cysts  can  be 
punctured;  if  the  disease  is  confined  to  one  portion  of  the  ovary, 
that  portion  can  be  resected,  especially  in  young  women 
who  desire  children;  if  the  whole  ovary  is  grossly  diseased, 
oophorectomy  is  necessary.  If  the  condition  is  bilateral, 
a  small  portion  of  one  ovary  should  be  saved,  if  possible, 
to  avoid  the  surgical  menopause. 


204  DISEASES    OF    THE    OVARY 

VI.  Implantation  and  Transplantation  of  the  Ovary 

If,  after  castration,  a  piece  of  the  ovary  is  transplanted, 
preferably  into  the  muscle  of  the  abdominal  wall,  or  between 
the  leaves  of  the  broad  ligament,  the  follicles  continue  for 
awhile  to  ripen  and  menstruation  can  be  maintained. 
Eventually,  and  in  a  comparatively  short  space  of  time, 
atrophy  takes  place,  and  menstruation  ceases. 

In  a  few  cases,  where  the  ovary  has  been  transplanted  into 
the  uterine  cornu  or  tube,  pregnancy  has  occurred,  even 
when  the  ovary  is  transplanted  from  one  individual  into 
another. 

If  a  piece  of  ovary  is  transplanted  into  the  muscular  layer 
of  the  abdominal  wall,  or  into  the  broad  ligament,  to  prevent 
the  surgical  menopause,  thin  slices  and  not  the  whole  ovary, 
are  used.  The  whole  ovary  is  sure  to  undergo  cystic  de- 
generation. In  the  slices,  a  satisfactory  blood  supply  is  much 
more  quickly  established. 

VII.  Solid  Tumors  of  the  Ovary 

Solid  tumors  of  the  ovary  are  (i)  benign  or  (2)  malignant. 
The  benign  are  fibromata;  the  malignant  carcinoma,  endo- 
thelioma and  sarcoma. 

Fibromata  are  entirely  benign  and  while  they  often  cause 
ascites,  this  disappears  after  their  removal  and  they  do  not 
recur.  They  are  subject  to  calcareous  degeneration  and 
become  as  hard  as  stone.  They  are  moderate  in  size,  of  very 
slow  growth,  pedunculated  and  rarely  bilateral.  They  occur 
at  any  time  of  life,  give  few  if  any  symptoms,  unless  they 
twist  on  their  pedicle,  or  cause  excessive  ascites.  By  bi- 
manual examination  they  are  felt  as  hard,  very  firm,  rounded 
tumors,  usually  very  freely  moveable.  They  should  be  re- 
moved because  of  the  possibility  of  twisted  pedicle  and  because 
of  the  associated  ascites. 

Malignant  Solid  Tumors. — (i)  Carcinoma  is  primary  or 
metastatic.     It  is  usually  medullary,  commonly  cystic,   and 


ABNORMALITIES    AND   DISEASES  205 

is  most  frequent  as  a  degeneration  of  a  papillary  cyst.  They 
are  moderate  in  size,  round  and  pedunculated.  Metastatic 
cancer  comes  from  the  uterus,  tube,  bowel  or  even  from  dis- 
tant organs  like  the  liver. 

Cancer  is  commonest  between  forty-five  and  fifty  years. 
It  is  usually  bilateral,  grows  rapidly  and  causes  marked  ascites. 
Pain  is  almost  constant  and  is  early  and  intense.  Cachexia 
comes  late  but  progresses  rapidly. 

Diagnosis. — Bimanual  examination  shows  a  round,  moder- 
ately soft  tumor,  with  marked  ascites.  The  growth  is 
often  mistaken  for  a  uterine  fibroid.  Because  of  the  pain 
and  ascites,  its  malignant  character  is  fairly  obvious. 

Treatment. — Immediate  operation,  with  removal  of  the 
uterus  and  both  ovaries,  even  though  the  disease  is  uni- 
lateral. 

Prognosis. — Recurrence  is  the  rule,  in  almost  90  per  cent. 
The  recurrences  do  not  respond  to  x-ray  or  radium;  re-opera- 
tion is  useless. 

(2)  Endotheliomata  are  derived  from  the  endothelium  of  the 
lymph-channels  and  blood-vessels.  They  are  an  inter- 
mediate form  of  growth,  between  cancer  and  sarcoma. 

Clinically  their  symptoms  and  treatment  are  those  of 
cancer. 

(3)  Sarcomata  are  spindle-celled,  round-celled  or  mixed. 
About  25  per  cent,  are  bilateral.  They  are  very  much  like 
fibromata  in  appearance,  but  of  rapid  growth.  They  give 
metastasis  early,  into  the  retroperitoneal  lymph  glands  and 
to  the  visceral  and  parietal  peritoneum. 

They  occur  at  any  age,  and  are  the  commonest  solid  ovarian 
tumor  in  childhood.  The  younger  the  patient  the  more  likely 
a  round-celled  sarcoma,  and  these  cases  are  nearly  always 
bilateral.  Ascites  is  marked,  as  it  is  in  all  solid  ovarian  tu- 
mors. Clinically  the  symptoms  and  treatment  are  the  same  as 
cancer. 

Prognosis. — It  is  not  quite  as  malignant  as  cancer,  but 
recurrence  can  be  expected  in  at  least  66  per  cent. 


206  DISEASES    OF    THE    OVARY 

vni.  Tuberculosis  of  the  Ovary 

Tuberculosis  of  the  ovary  is  secondary  from  the  tube  or 
peritoneum.  It  is  very  doubtful  if  it  is  ever  primary.  Miliary 
peritoneal  tuberculosis  attacks  the  surface  of  the  ovary  but  not 
its  stroma. 

The  symptoms  and  treatment  are  the  same  as  tubercular 
salpingitis. 


CHAPTER  X 

DISEASES  OF  THE  PERITONEUM  AND  PELVIC 
CONNECTIVE  TISSUE 

General  Anatomy. — The  pelvic  peritoneum  covers  all  the 
pelvic  viscera  except  the  ovaries.  It  dips  into  Douglas'  pouch, 
thence  up  over  the  posterior  uterine  surface,  over  the  fundus 
uteri,  along  the  anterior  uterine  wall  and  over  the  top  of  the 
bladder  and  becomes  continuous  with  the  parietal  peritoneum 


Pig.   77. — Heavy   black    lines   indicate   reflection    of    peritoneum.      Note 
the  difference  in  the  anterior  and  posterior  uterine  reduplication. 

of  the  anterior  abdominal  wall.     The  uterorectal  pouch   or 
Douglas'  pouch  is  deeper  than  the  uterovesical. 

The  pelvic  connective  tissue  (pelvic  cellular  tissue)  fills 
the  space  under  the  pelvic  peritoneum  and  in  the  bases  of  the 
broad  ligaments.     That  lying  near  the  uterus  is   the  para- 

207 


2o8  DISEASES    OF    THE   PERITONEUM 

metrium;  near  the  bladder,  the  paracystium;  near  the  rectum, 
the  parapr odium.  The  general  term  for  inflammation  of  any 
portion  of  the  cellular  tissue  is  pelvic  cellulitis. 

I.  PELVIC  CELLULITIS  (PARAMETRITIS) 

This  is  always  due  to  infection,  and  is  most  common  in  that 
portion  near  the  uterus. 

Pathology. — (i)  The  overlying  peritoneum  is  always  in- 
volved;    (2)    the    process    is    first    edema,    then    round-cell 


Fig.  78. — The  areas  involved  in  pelvic  cellulitis.  I.  Broad  ligaments. 
2.  Base  of  broad  ligaments  and  lateral  vaginal  fornices.  3.  Ischio- 
rectal fossag. 

infiltration,  then  either  suppuration  or,  by  absorption  of  the 
edema,  a  dense  pelvic  exudate;  (3)  the  veins  passing  through 
the  tissue  involved  are  always  thrombotic,  and  wide  extension 
of  the  thrombosis  is  possible;  (4)  suppuration  is  often  wide- 
spread and  the  abscess  may  break  into  neighboring  organs, 
usually  the  rectum,  vagina  or  bladder. 

Causes. — (i)  Secondary  to  puerperal  sepsis;  ('2)  secondary 
to  abdominal  operation  (most  often  hysterectomy  for  pelvic 
inflammation);  (3)  secondary  to  salpingitis;  (4)  perforation 
of  the  uterus,  at  curettage;  (5)  possibly  spontaneous,  from 
lowered  resistance  and  colon  bacillus  infection. 


PELVIC   CELLULITIS    (PARAMETRITIS)  209 

Terminations. — (i)  Complete  resolution;  (2)  resolution  with 
pelvic  exudate  and  adhesions;  (3)  pelvic  abscess;  (4)  rupture 
into  bowel,  bladder,  or  vagina;  (5)  diffuse  peritonitis  and 
death;  (6)  general  septicemia. 

Symptoms. — i.  General  symptoms  of  infection:  (i)  Fever; 
(2)  rapid  pulse;  (3)  leukocytosis  (18,000-20,000);  (4)  pelvic 
pain;  (5)  chills.  Local  symptoms  are  characteristic;  the  cervix 
is  firmly  fixed,  usually  displaced  forward  or  to  one  side,  and  the 
tissues  beyond  the  vaginal  vaults  are  as  hard  as  stone. 

Differential  diagnosis  from  pelvic  peritonitis  is  largely 
theoretical.  In  pelvic  peritonitis  the  greatest  induration 
should  be  anteroposteriorly;  in  cellulitis,  laterally.  As 
the  two  are  always  associated,  this  dis- 
tinction is  of  no  value.  Diagnosis  from 
a  pelvic  hematocele,  the  only  other 
condition  simulating  cellulitis,  is  im- 
possible without  operation. 

Treatment.' — Palliative:  The  majority 
of  cases  subside  without  suppuration 
under  palliative  treatment:  (i)  Rest  in^  fig. . TpT^agram  to 
bed;  (2)  liquid  diet;  (3)  moderate  lax-"  illustrate  the  difference 
atives;  (4)  ice  bag  to  lower  abdomen;  "..^^raM  Sit£ 

(5)    hot  vaginal    douches   Qy'2  OZ.  salt  to    Practically  this  is  of  Uttle 

Civ.-  hot  water,  1.0°  F.)  four  times  a  -.t^^  *:.;;r  "'  » 
day;  (6)  tampons  do  no  good  and  often 

harm.     If  in  a  week  of  this  treatment,  there  is  not  marked 
improvement,  operation  will  usually  be  necessary. 

Operative  Treatment. — Indications:  (i)  When  there  is  no 
improvement  after  palliative  treatment;  (2)  persistent  fever 
and  chills;  (3)  persistent  high  leukocyte  count;  (4)  softening 
of  the  pelvic  mass,  bulging  of  the  lateral  or  posterior  vaginal 
vaults. 

If  there  is  any  doubt  as  to  the  mass  being  extra  or  intra- 
peritoneal, exploratory  section  is  indicated.     If  the  mass  is 
intraperitoneal,  it  is  drained  through  the  lower  end  of  the 
abdominal  incision;  if  extraperitoneal,  the  abdominal  wound 
14 


2lO 


DISEASES    OF    THE   PERITONEUM 


is  closed  and  the  abscess  drained  through  the  posterior  vaginal 
vault. 

Pointing  of  the  Abscess. — Most  commonly,  the  pus  burrows 
between  the  vagina  and  rectum,  bulging  the  posterior  vaginal 
vault  forward.  Depending  upon  the  point  of  infection,  it  may 
point  in  the  thigh,  perineum,  abdomen  or  even  the  back,  but  the 
posterior  vaginal  vault  is  overwhelmingly  the  most  common. 

Posterior  vaginal  section  (posterior  colpotomy)  is  the  opera- 
tion of  choice,  if  the  abscess  is  extraperitoneal. 

Technic. — (i)  The  patient  is  arranged  in  the  dorsal  position, 
prepared  as  for  any  vaginal  operation  and  anesthetized. 


Pig.   8o. — Opening  a  pelvic  abscess  through  Douglas'  pouch. 

2.  The  posterior  lip  of  the  cervix  is  seized  with  a  double 
tenaculum. 

3.  A  semicircular  incision  is  made,  through  the  vaginal 
mucosa  at  its  attachment  to  the  cervix. 

4.  A  long-handled,  curved,  sharp-pointed  scissors,  with  the 
blades  closed,  is  plunged  in  the  mass,  keeping  strictly  to 
the  middle  line  and  close  to  the  uterus.  The  blades  are  widely 
opened  and  withdrawn  open. 

5.  To  secure  a  wider  space,  the  opening  is  dilated  with  ordi- 
nary branched  uterine  dilators. 


PELVIC   CELLULITIS    (PARAMETRITIS).  211 

6.  The  cavity  is  explored  with  the  finger  (to  avoid  hemor- 
rhage and  injury  to  the  ureter)  and  all  palpable  septa  are 
broken. 

7.  The  cavity  is  washed  out  with  sterile  water. 

8.  If  much  pus  was  found,  the  cavity  is  drained  at  once 
with  a  large  T-tube.     If  only  broken-down  cellular  tissue  and 


Fig.  81.  Fig.  82. 

Pig.  81. — T-shaped  rubber  drain.  It  is  important  that  the  rubber 
tubing  be  of  large  caHber,  to  prevent  occlusion  by  clots.  The  straight 
bar  extends  completely  through  the  T  arm,  so  that  drainage  is  in  a  straight 
line.  The  function  of  the  cross  bar  is  solely  to  hold  the  tube  in.  {B.C. 
Hirst.) 

Fig.  82. — T  rubber  drain  seized  in  grip  of  dressing  forceps  preparatory 
to  insertion  through  hole  in  vaginal  vault.      {B.  C.  Hirst.) 

little  pus  was  found,  the  cavity  is  packed  with  gauze  for  forty- 
eight  hours;  the  gauze  is  then  removed  and  a  T-tube  inserted. 
9.  Through  the  tube,  which  is  cut  off  so  as  to  project  about 


212 


DISEASES    OF   THE   PERITONEUM 


one-half  inch  from  the  vulva,  the  pelvis  is  irrigated  once  daily 
and  the  tube  is  not  removed  untU  the  temperature  is  persist- 
ently normal  and  all  pus  has  ceased. 

If  the  pelvic  cellulitis  is  due  to  a  large  pyosalpinx,  palliative 
treatment  and  abdominal  section  after  the  acute  symptoms 
have  subsided  is  better  than  vaginal  section.  This  latter  may 
have  to  be  done  as  a  life-saving  measure,  but  it  always  compH- 
cates  the  section. 


Fig.  83. — Drainage  of  a  pelvic  abscess,  with  a  T  rubber  drainage  tube. 


Prognosis. — (i)  Puerperal  infections  are  not  as  favorable  as 
the  non-puerperal;  (2)  the  end  result  is  usually  one  of  chronic 
pelvic  cellulitis,  requiring  prolonged  treatment;  (3)  prolonged 
necrosis  in  the  cellular  tissue  may  prove  fatal;  (4)  phlegmasia 
alba  dolens  (milk  leg)  and  pulmonary  embolus  are  not 
uncommon. 

Chronic  Cellulitis. — After  the  acute  stage  has  subsided  and 
resolution  is  established,  or  after  posterior  colpotomy,  there 
often  remains  induration  of  the  uterosacral  ligaments  and 
bases  of  the  broad  ligaments,  without  fever  or  leukocytosis, 
but  with  considerable  pain:  The  thickened  areas  can  be  felt 
plainly,  by  vaginal  examination. 

Treatment. — (i)    Hot    vaginal    douching;    (2)    boroglycerid 


PELVIC   HEMATOCELE    (PARAMETRIAL   HEMATOMA)         213 

tampons;  (3)  7  per  cent,  tincture  of  iodin  to  vaginal  vaults, 
once  weekly;  (4)  laxatives;  (5)  avoidance  of  coitus  or  any 
other  cause  of  pelvic  congestion  (heavy  exercise  or  work, 
cold  baths,  rest  at  time  of  periods,  etc.). 


Pig.   84. — A  pelvic  abscess  opened  through  the  posterior  vaginal  vault  and 
drained  with  gauze. 


11.  PELVIC  HEMATOCELE  (PARAMETRIAL  HEMATOMA) 

This  is  a  collection  of  blood  in  the  uterorectal  or  uterovesical 
pouch,  or  between  the  layers  of  the  broad  ligament. 

Causes.- — (i)  Much  the  commonest  is  tubal  abortion  in 
extra-uterine  pregnancy;  (2)  injuries  to  the  uterine  walls  (rup- 
ture or  perforation) ;  (3)  imperfect  hemostasis  after  operations, 
especially  hysterectomy;  (4)  rupture  of  a  varicose  vein  in  the 
broad  ligament. 

Symptoms.^ — (i)  Essentially  those  of  cellulitis,  with  less 
fever  and  leukocytosis,  unless  the  hemorrhage  is  sudden  and 
profuse;  (2)  in  the  latter  case,  shock,  signs  of  internal  bleeding 
and  acute  anemia;  (3)  after  the  mass  is  encapsulated  by  adhe- 
sions, pressure  on  bowel  and  bladder  are  marked;  (4)  at  any 
time  it  is  subject  to  infection  from  colon  bacilli  and  abscess 
formation. 


214  DISEASES    OF   THE   PERITONEUM 

Diagnosis.- — ^Bimanual  examination  shows  the  same  pelvic 
mass  as  cellulitis. 

Treatment.^ — (i)  If  the  hemorrhage  is  acute  and  severe,  as  in 
extra-uterine  pregnancy,  abdominal  section,  tie  the  affected 
tube  and  remove,  and  remove  blood  clots  by  flushing  the 
abdomen  with  sterile  water.  (2)  If  old  and  encapsulated 
palliative  treatment  as  described  in  cellulitis,  and  posterior 
colpotomy  and  drainage  only  if  it  becomes  infected. 

III.  PERITONITIS 

Peritonitis  may  be  either  (i)  local  or  (2)  diffuse.  It  is 
localized:  (i)  in  the  pelvis,  either  in  Douglas'  pouch  or  in  the 
uterovesical  space,  secondary  to  either  a  tubal  or  uterine 
infection;  (2)  around  the  appendix;  (3)  around  intestinal 
perforations;  (4)  around  the  gall-bladder. 

Diffuse  peritonitis  is  most  common  from  (i)  acute  appendici- 
tis with  perforation;  (2)  streptococcic  infection  after  labor  or 
miscarriage;  (3)  rupture  of  gonorrheal  pyosalpinx;  (4)  per- 
foration of  stomach  or  bowel;  (5)  perforation  of  gall-bladder. 

Tjrpes. — (i)  Serous,  with  ascites;  (2)  seropurulent;  (3) 
purulent;  (4)  plastic  (tubercular  usually);  (5)  fulminant. 

Pelvic  peritonitis  is  much  most  commonly  due  to  gonorrhea. 
Every  case  of  gonorrheal  salpingitis  is  accompanied  by  pelvic 
peritonitis.  It  is  also  associated  with  all  cases  of  cellulitis. 
The  symptoms  and  treatment  are  the  same  as  cellulitis. 

Diffuse  peritonitis  is  a  much  more  dangerous  type.  That 
from  a  perforated  appendix  is  the  least  dangerous;  that  from 
streptococcic  infection  of  the  uterus,  tubes  or  ovaries  the  most 
fatal. 

Symptoms. — (i)  Great  abdominal  pain;  (2)  usually  but  not 
invariably,  abdominal  rigidity;  (3)  fever  (which  is  usually 
much  higher  by  rectal  temperature);  (4)  leukocytosis;  (5) 
peritonitis  decubitus;  (6)  rapid,  thready,  wiry  pulse;  (7) 
paresis  of  the  bowel,  with  absence  of  peristalsis  and  apparent 
obstruction;  (8)  increasing  abdominal  distention. 

The  treatment  is  abdominal  section,  removal  of  the  cause, 


PERITONITIS  215 

if  one  can  be  found,  flushing  of  the  abdomen  with  large  quanti- 
ties of  sterile  salt  solution,  drainage  by  rubber  or  glass  tube. 
Fowler  position  and  active  stimulation.  The  prognosis  is 
always  doubtful.  It  is  best  in  appendiceal  cases;  worst  in 
streptococcic.  In  these  latter  there  is  often  a  deceptive  im- 
provement for  a  few  hours,  and  then  a  rapid  change  for  the 
worse  and  death  in  a  short  time. 

Tubercular  peritonitis  occurs  in  three  forms:  (i)  Diffuse 
miliary  tuberculosis,  always  with  ascites.  This  is  the  type 
most  common  in  the  young;  (2)  diffuse  peritonitis,  with  exten- 
sive adhesions,  without  ascites.  This  is  the  plastic  or  chronic 
adhesive  type;  (3)  nodular  tubercular  peritonitis,  with  numerous 
nodes  in  the  peritoneum  and  mesentery.  This  type  is  the 
rarest,  and  most  often  mistaken  for  cancer. 

The  source  of  tubercular  peritonitis  is:  (i)  Secondary  to 
tuberculosis  of  the  tubes  (most  common);  (2)  by  blood-current 
infection  from  active  foci  elsewhere  in  the  body. 

Symptoms  vary  with  the  type  of  the  disease.  In  the  first 
tj^e;  there  are  often  no  symptoms  until  considerable  ascites 
has  collected.  The  patient  is  ill-developed,  thin,  often  with 
amenorrhea,  often  shows  general  constitutional  symptoms  such 
as  night  sweats,  slight  fever  and  digestive  disturbances.  The 
ascites  is  often  sufficient  to  cause  considerable  distention  and 
dyspnea. 

The  symptoms  of  the  second  type  are  the  same,  except  for 
less  distention  and  more  abdominal  pain. 

The  symptoms  of  nodular  peritonitis  are  more  grave.  The 
patient  is  obviously  seriously  ill,  with  fever  and  rapid  pulse; 
there  is  often  pus  and  blood  in  the  stools  and  even  in  the 
urine;  the  nodular  masses  can  be  felt,  and  because  this  type 
occurs  in  patients  in  middle  life,  cancer  is  likely  to  be  suspected. 

Diagnosis. — In  the  ascitic  type,  marked  ascites  in  a  patient 
(especially  in  youth)  not  associated  with  kidney,  heart  or  liver 
disease,  is  almost  certainly  of  tubercular  origin. 

The  tuberculin  and  von  Pirquet  tests  are  not  conclusive, 
though  valuable  presumptive  signs. 


2l6  DISEASES    or    THE   PERITONEUM 

In  the  second  and  third  types,  accurate  diagnosis  is  often 
impossible,  exploratory  section  being  the  only  means  of  making 
certain. 

Treatment. — Ascites,  if  excessive,  is  best  removed  by  a  small 
incision,  rather  than  tapping,  because  of  the  danger  of  perforat- 
ing an  adherent  coil  of  intestine.  If  the  Fallopian  tubes  are 
affected  they  should  be  removed,  as  little  handling  of  the 
intestines  as  possible  being  essential,  and  the  abdomen  closed. 
In  the  plastic  type,  the  adhesions  are  usually  too  extensive 
to  be  broken  up,  and  the  abdomen  should  be  closed  without 
meddlesome  attempts  to  achieve  the  impossible. 

In  the  nodular  type,  the  abdomen  is  closed  at  once,  with- 
out attempt  at  removal  of  any  of  the  nodes. 

No  tubercular  peritonitis  case  should  ever  he  drained,  as  a 
permanent  fistula  is  sure  to  result. 

Prognosis  is  usually  good.  Astonishing  improvement  and 
often  complete  symptomatic  cure  will  follow  a  simple  explora- 
tory section.  No  definite  reason  can  be  proven  for  this, 
though  these  theories  are  advanced;  (i)  admission  of  light 
and  air  (doubtful);  (2)  change  from  the  ascitic  to  the  plastic 
type,  by  evacuation  of  the  ascites;  (3)  the  old  ascitic  fluid  is 
replaced  by  fresh,  with  a  high  bacteriolytic  power. 

IV.    DRAINAGE  OF  THE  ABDOMEN   AFTER  OPERATION 
FOR  PELVIC  INFECTION 

Indications. — (i)  All  streptococcic  cases,  without  exception; 

(2)  Abscess  sacs,  difficult  or  impossible  of  enucleation;  (3) 
where  intestine  is  injured  and  perforation  is  feared  (here 
by  tube  or  rubber  tissue  only  and  never  gauze) ;  (4)  to  control 
bleeding;  (5)  diffuse  peritonitis. 

Contra-indications. — (i)  Tubercular  peritonitis;  (2)  syphilis; 

(3)  in  any  case  of  doubt  as  to  the  necessity,  do  not  drain. 
Dangers     of    Drainage. — (i)    Intestinal    obstruction;    (2) 

adhesions;  (3)  perforation  of  bowel;  (4)  hemorrhage  when  drain 
is  withdrawn. 

Methods  of  Drainage.^ — (i)  By  tube  and  gauze,  through  the 


DRAINAGE   OF   THE   ABDOMEN 


217 


lower  end  of  the  abdominal  wound;  (2)  by  tube  or  gauze  through 
Douglas'  pouch,  into  the  vagina;  (3)  by  a  combination  of  the 
above,  or  through-and-through  drainage. 

The  best  method,  where  drainage  is  needed  for  infection,  is 
by  glass  tube  and  gauze  through  the  lower  end  of  the  abdominal 
incision.  This  is  especially  necessary  in  cases  of  streptococcic 
infection. 

Technic. — (i)  Just  before  the  abdomen  is  closed  the  pelvis 
is  sponged  as  clean  as  possible. 

2.  A  curved  glass  drainage  tube  about  the  size  of  the  fore- 


PiG.  85. — Abdominal  drainage  by  glass  tube  and  gauze;  the  most  ef- 
ficient type  of  drainage  in  septic  conditions  in  the  pelvis. 


finger  is  put  in  the  bottom  of  Douglas'  pouch.  The  curved  is 
better  than  the  straight  tube,  because  it  can  be  brought  out 
nearer  the  symphysis,  and  hence  lessens  the  danger  of  hernia. 
3.  Under  and  around  the  tube  is  packed  a  gauze  strip,  usually 
four  layers  one  and  one-half  inches  wide  (made  by  folding  a  six- 
inch  bandage),  so  that  the  entire  pelvis  and  all  the  intestines 
held  above  the  pelvic  brim.  The  end  of  the  gauze  is  brought 
out  along  the  tube. 


2l8  DISEASES    OF   THE  PERITONEUM 

4.  The  protective  sponges  are  now  removed  and  the  abdomen 
closed  around  the  tube  and  gauze. 

The  vaginal  method  of  drainage  (through  an  opening  in 
Douglas'  pouch)  is  not  safe,  in  septic  cases,  and  should  be 
avoided. 

After-care. — (i)  Every  twenty-four  hours,  the  glass  tube  is 
sucked  out,  by  a  piston  syringe  and  catheter,  for  the  first  five 
days.  The  amount  of  fluid  will  diminish  from  about  an  ounce 
the  first  day  to  a  couple  of  drams  on  the  fifth.  (2)  The  patient 
is  kept  in  the  Fowler  position  and  the  Murphy  drip  (glucose  one 
and  a  half  ounces,  sodium  bicarbonate  one  and  a  hah  ounces, 
water  two  pints,  forty  drops  a  minute,  temperature  kept  near 
1 10°)  is  used.  (3)  All  these  patients  need  rather  active  stimu- 
lation, particularly  in  the  second  twenty-four  hours.  (4)  On 
the  fifth  day  the  glass  tube  is  removed.  (5)  Beginning  on  the 
sixth  day,  the  gauze  is  removed,  taking  out  about  one-quarter 
of  the  total  amount  each  day,  so  that  by  the  tenth  or  eleventh 
day,  it  is  all  out.  (6)  As  soon  as  the  last  of  the  gauze  is  out,  a 
rubber  tube  is  inserted,  in  the  sinus  left  by  the  gauze,  as  deep  as 
it  will  go,  and  a  safety  pin  put  through  the  outer  end.  (7) 
Through  this  tube  the  pelvis  is  flushed  daily  with  sterile  water, 
run  in  by  gravity,  and  the  tube  shortened  as  it  is  pushed  out 
from  below.  (8)  The  usual  convalescence  lasts  four  to  six  weeks. 
Except  for  these  points,  the  after  care  is  that  of  the  ordinary 
section. 

Drainage  through  the  posterior  vaginal  vault  is  indicated 
chiefly  for  bleeding  from  intractable  oozing,  in  cases  without 
active  infection. 

Technic. — (i)  An  assistant  places  two  fingers  of  one  hand 
in  the  vagina,  making  strong  pressure  upward  in  the  posterior 
vaginal  vault,  with  the  finger  tips  separated. 

2.  The  operator,  with  these  fingers  as  a  guide,  perforates 
between  them,  with  scissors,  into  the  posterior  vaginal  vault. 

3.  The  end  of  the  gauze  packing  is  grasped  in  a  clamp  and 
pushed  into  the  vagina,  where  the  assistant  grasps  the  packing 
and  pulls  it  through  for  a  short  distance. 


PHLEBOLITHS  219 

4.  The  pelvis  is  packed  full  and  the  abdomen  closed. 

5.  The  vagina  is  repacked,  with  fresh  packing,  after  the 
operation  is  completed. 

After-care.- — ^The  packing  is  left  undisturbed  for  four  days, 
is  then  gradually  removed  over  another  four  days  and  the 
drainage  hole  kept  open  by  a  T-tube,  if  there  is  much  discharge. 

V.    PHLEBOLITHS 

Phleboliths  are  calcified  thrombi  in  the  dilated  pelvic  veins. 
They  are  of  no  clinical  importance  and  do  not  justify  operation. 
They  often  cause  deceptive  shadows  in  a;-ray  plates  and  lead 
to  erroneous  diagnosis  of  ureteral  stones,  even  when  the 
picture  is  taken  with  catheters  in  place. 


CHAPTER  XI 

ABNORMALITIES  OF  THE  ABDOMINAL  WALL 
I.  DIASTASIS  OF  THE  RECTI  WITH  GENERAL  VISCEROPTOSIS 

In  the  last  three  months  of  every  pregnancy  the  abdominal 
recti  are  gradually  separated,  by  the  pressure  of  the  enlarging 
uterus.  In  cases  of  hydramnios  or  multiple  pregnancy  where 
the  abdomen  is  overdistended,  the  separation  may  be  extreme. 
If  an  abdominal  binder  is  worn,  and  kept  properly  tight,  during 
the  puerperal  convalescence,  the  muscles  gradually  assume 
their  normal  parallel  course,  and  the  support  of  the  anterior 
abdominal  wall  is  not  markedly  diminished.  Where  the 
abdominal  binder  is  not  worn,  or  discarded  too  soon,  or  not 
kept  properly  tight,  permanent  separation,  with  consequent 
splanchnoptosis  and  pendulous  abdomen  wiU  result.  The 
effects  of  a  diastasis  are  chiefly  those  of  splanchnoptosis  and 
practically  a  ventral  hernia.  The  patient,  if  the  diastasis  is 
marked,  is  incapacitated. 

Diagnosis  is  easy.  The  abdominal  skin  is  flaccid  and  wrink- 
led; coils  of  intestine  can  plainly  be  seen  moving  under  the 
thin  skin  and  fascia;  when  the  patient  strains,  the  center  of  the 
abdomen  rises  like  a  dome,  and  the  edges  of  the  separated 
muscles  can  be  felt. 

Treatment.- — A  separation  of  less  than  four  fingers  in  breadth 
can  usually  be  disregarded,  as  the  symptoms  are  so  moderate 
that  no  relief  is  needed.  Greater  separation  than  this  gives 
symptoms  whose  severity  is  in  direct  ratio  to  the  degree  of 
separation.  A  moderate  case  can  be  relieved,  temporarily  at 
least,  by  an  abdominal  binder,  preferably  one  which  supports 
the  abdomen  as  well  as  compresses. 

A  straight  front  corset  will  give  good  support;  adhesive 
straps  will  give  temporary  relief.     Massage  and  electricity 


EXSTROPHY   OF   THE  BLADDER  221 

are  not  likely  to  have  any  beneficial  effect.  Exercises  tending 
to  strengthen  the  abdominal  muscles  often  help  the  moderate 
cases  greatly,  but  are  useless  where  the  separation  is  over  four 
or  five  fingers.  All  these  methods  are  merely  temporary  (except 
possibly  after  the  first  labor)  and  cannot  be  used  in  women 
obliged  to  do  hard  work.  In  these  patients,  the  Webster 
operation  will  effect  a  cure.  The  principle  is  a  long  incision 
from  the  ensiform  to  the  pubes,  dissecting  back  the  skin  and 
fat  on  each  side  to  the  retracted  muscles.  In  this  process 
the  peritoneal  cavity  is  usually  opened  as  the  umbilicus  is 
cut  across.  The  small  opening  is  closed  at  once,  and  the  rest 
of  the  operation  is  extraperitoneal.  The  sheaths  of  the  sepa- 
rated recti  are  sewed  together  without  opening  them,  in  the 
middle  line,  using  interrupted  chromic  catgut  number  2  for 
tension  sutures  and  continuous  number  i  chromic  catgut  stitch 
for  approximation.  The  tissue  lying  between  the  muscles, 
is  allowed  to  arrange  itself  behind  the  suture  line,  and  is  not 
excised.  The  excess  of  the  skin  is  trimmed  off,  and  if  desired, 
a  new  umbilicus  can  be  made,  by  a  purse-string  suture  inverting 
the  skin  edge,  at  the  proper  point. 

This  operation  withstands  subsequent  labor  provided  it  does 
not  occur  too  soon  after  the  operation  (two  years  at  least) 
and  proper  attention  is  given  to  the  abdominal  binder  during 
puerperal  convalescence. 

II.  EXSTROPHY  OF  THE  BLADDER 

Exstrophy  of  the  bladder  is  a  rare  condition  where  a  part  of 
the  anterior  abdominal  wall,  together  with  the  fundus  of  the 
bladder  is  missing,  and  the  interior  of  the  bladder  is  exposed. 
It  is  associated  also  with  failure  of  development  of  the  sym- 
physis. There  is  naturally  complete  incontinence  of  urine. 
The  defect  can  be  remedied,  in  part  at  least,  with  flaps  taken 
from  the  abdominal  wall  from  above  and  from  each  side. 

IIL  HERNIA 
Hernia  may  be:  (i)  umbiHcal;  (2)  incisional;  (3)  inguinal; 
(4)  femoral. 


222 


ABNORMALITIES    OF    THE    ABDOMINAL   WALL 


Abdominal  hernia  is  much  more  common  in  women  than  in 
men,  and  unless  diastasis  of  the  recti  be  called  a  hernia,  umbil- 
ical is  the  commonest  type. 

Umbilical  hernia  varies  in  size  from  a  small  protrusion  to  an 
enormous  sac,  containing  most  of  the  intestines.  There  is  a 
well-defined  ring,  and  a  marked  tendency  for  the  omentum 
and  intestines  to  adhere  to  the  sac.  Incarceration,  strangula- 
tion and  intestinal  obstruction  are  common  complications. 
In  all  umbilical  hernias  there  is  coincident  diastasis  of  the 
recti. 

Symptoms. — (i)  Protrusion  of  the  umbilicus;  (2)  abdominal 
pain;  (3)  often  constipation  (due  in  part  to  the  adherent  bowel); 


Umbilicus 


Hernial  Sac 


Separated 
Rectus  M 


Abctommal 
■      Tot 


Pig.  86. 


-A  lateral  view  of  an  incarcerated  umbilical  hernia. 
{After  Graves.) 


(4)  symptoms  of  strangulation  (pain,  vomiting  and  obstruction) 
if  this  takes  place. 

The  diagnosis  is  sufi&ciently  obvious,  due  to  the  protruding 
sac  at  the  umbilicus. 

Treatment. — (i)  Palliative,  by  the  use  of  an  abdominal  binder, 
abdominal  corset  or  by  adhesive  straps.  It  is  difficult  in 
many  cases  to  get  a  properly  fitting  corset  or  binder,  due  to  the 
obesity  of  the  patient.  Adhesive  straps  irritate  the  skin,  if 
used  for  any  length  of  time.  PaUiative  treatment  is  recom- 
mended only  if  there  is  an  absolute  contra-indication  to  opera- 
tion, or  if  the  patient  refuses  operation. 


HERNIA 


223 


(2)  Operative. — If  the  hernia  is  large  and  the  patient  fat, 
the  operation  is  a  dangerous  one.  The  chief  compHcations 
are:  (i)  local  infection  and  fat  necrosis;  (2)  embolism;  (3) 
pneumonia;  (4)  effects  of  anesthesia  (on  heart  and  kidneys). 
Recurrences  are  not  infrequent  and  are  much  harder  to  manage 
than  the  original  hernia. 

Techmc.—{i)  A  long  incision  is  made  in  the  middle  line, 
encircling  the  protruding  mass. 

2.  The  sac,  often  found  considerably  to  one  side  of  the  mid- 
line,   is    dissected    out    and 

opened.  -^^^  \  "^^'.^V  Sutures 

3.  All  adhesions  are  broken 
up,  the  contents  of  the  sac 
returned  to  the  abdomen, 
the  sac  tied  off  and  removed 
and  the  peritoneum  closed. 

4.  The  skin  and  fat  are 
dissected  back  until  the  firm 
white  aponeurosis  is  exposed. 

5.  The  edges  of  the  apon- 
eurosis are  united  with 
number  3  chromic  catgut 
interrupted  sutures,  left  for 
the  moment  untied. 

6.  Six  or  seven  silk- 
worm-gut sutures  are  in- 
serted, entering  through  the 
skin,  fat  and  fascia  on  one 
side  and  emerging  through  the  fascia,  fat  and  skin  on  the 
other.     Also  untied. 

7.  The  edges  of  the  fascia  are  united  by  a  continuous  number 
I  chromic  catgut  stitch,  tying  each  interrupted  stitch  as  it  is 
reached. 

8.  The  skin  is  closed  and  the  silkworm-gut  stitches  tied. 
The  .wound  is  dressed  as  usual,  and  dressings  are  changed  in 
forty-eight  hours  due  to  the  excessive  serous  oozing.     Patients 


, .  pectus 
JVluscles 


Fig.   87. — The  closure  of  a  ventral 
hernia.      {After  Graves.) 


224  ABNORliALlTIES    OF    THE   ABDOMINAL   WALL 

are  kept  in  bed  at  least  three  weeks,  the  silkworm-gut  sutures 
removed  in  the  third  week.  The  same  principle  of  operation 
may  be  carried  out  through  a  transverse  incision  (Mayo) 
though  there  is  no  special  gain  in  so  doing. 

Incisional  Hernia,  after  Abdominal  Operation. — Causes: 
(i)  Drainage;  (2)  infection;  (3)  premature  absorption  of  catgut; 
(4)  excessive  muscular  exertion,  or  strain  within  a  few  months 
of  the  operation. 

Development. — First  there  is  a  small  protrusion  at  one  point, 
usually  one  end  of  the  wound.  It  is  tender  and  has  impulse 
on  coughing  or  straining.  It  gradually  grows,  until  it  involves 
the  whole  wound  and  extends  to  either  side.  There  may  be 
a  single  ring  or  several,  each  with  its  own  sac.  The  contents 
are  usually  omentum  and  this  is  always  adherent.  These 
adhesions  usually  prevent  the  entrance  of  intestine,  but  not  if 
the  ring  grows  large.  There  is  marked  tendency  to  strangula- 
tion and  obstruction,  after  intestine  has  entered  the  sac. 

Diagnosis  is  usually  easy,  as  the  protrusion  is  obvious  and 
the  edges  of  the  ring  or  rings  can  be  plainly  felt. 

Treatment  is  essentially  the  same  as  that  given  for  umbilical 
hernia,  both  palliative  and  operative,  except  that  a  transverse 
incision  cannot  be  utilized. 

It  not  infrequently  happens  that  the  edges  of  the  aponeurosis 
cannot  be  brought  together,  due  to  loss  of  tissue  from  infec- 
tion. This  difficulty  can  be  met  in  several  ways:  (i)  trans- 
plantation of  fascia  taken  from  the  thighs  (Bartlett's  method); 
(2)  placing  a  row  of  mattress  sutures  number  3  chromic  catgut, 
across  the  gap,  tying  them  as  tight  as  possible  and  trusting 
to  granulation  to  fill  up  the  meshes  between  the  stitches;  (3) 
sewing  in  a  silver  wire  mat,  which  must  later  be  removed. 

Recurrence  after  operation  is  disastrous,  as  it  is  much  worse 
than  the  original"  hernia. 

Inguinal  hernia  is  much  easier  to  manage  in  women,  as  the 
spermatic  cord  (in  this  case  the  round  ligament)  does  not 
have  to  be  considered.  The  fascia  covering  the  canal  is 
opened,  the  sac  opened,  its  contents  returned  to  the  abdomen 


OBESITY 


225 


and  the  sac  tied  off;  the  internal  ring  closed,  and  the  inguinal 
canal  obliterated  as  in  the  Bassini  operation. 

Femoral  hernia  is  managed  on  the  same  principles  in 
both  sexes.  It  is  often  complicated  by  acute  adenitis  of 
the  glands  at  the  femoral  ring  and  these  must  be  removed  at 
operation. 

IV.  OBESITY 

Obesity,  while  not  a  disease  of  the  abdominal  wall,  has  there 
its  most  marked  evidence.     It  is  a  source  of  considerable  dis- 


PlG. 


?. — Testing   the   actual   outline   of   the   abdomen,    by   eliminating 
the  superficial  fat. 


comfort  to  the  patient,  and,  because  it  is  frequently  attended 
by  sexual  underdevelopment,  she  may  be  sterile. 

Treatment.^ — (i)  Diet,  all  starches,  fats,  and  sugars  being 
eliminated  or  minimized;  (2)  regular  exercise  (the  hardest 
thing  to  get  these  fat  patients  to  do),  preferably  walking;  (3) 
frequent  hot  baths;  (4)  sufficient  laxatives  to  give  two  move- 
ments a  day;  (5)  thyroid  extract,  5  grains  three  or  four  times 
daily;   (6)  whole  pituitary  gland — the  anterior  lobe  being  a 

IS 


226 


ABNORMALITIES    OF   THE   ABDOMINAL   WALL 


sexual  developer,   the  posterior  lobe  limiting  carbohydrate 
absorption — four  grains  by  mouth  four  times  daily. 


Pig.   89. — Testing  the  abdomen  for  fluctuation  in  ascites.     The  hand  in 
the  center  stops  the  fat  wave  on  percussion. 

V.  PATENT  URACHUS 

Patent  urachus  usually  causes  an  umbilical  fistula,  with 
constant,  or  periodic,  purulent  discharge.  The  fistula  is 
excised  and  the  opening  packed. 

VL  TUMORS  OF  THE  ABDOMINAL  WALL 

Tumors  of  the  abdominal  wall  are:  (i)  Adenomyoma  of  the 
round  ligament;  (2)  fibrosarcoma  of  the  sheath  of  the  rectus; 
(3)  lipoma;  (4)  sarcoma,  often  invohdng  enormous  areas. 
Phantom  tumors  are  due  to  spasmodic  contraction  of  the 
recti.  They  disappear  under  anesthesia;  the  others  are 
permanent.  Myoma  of  the  round  ligament  is  in  the  groin, 
is  very  rare,  simulates  inguinal  adenitis  and  inguinal  hernia, 
and  should  be  removed.  The  inguinal  canal  must  be 
obliterated,  to  prevent  hernia. 


TUMORS    OF   THE   ABDOMINAL   WALL 


227 


Fibrosarcomata  are  small  hard  tumors,  growing  from  the 
sheath  of  the  recti  muscles,  and  are  in  the  midline.  They 
should  be  removed,  and  are  very  slightly  malignant. 

Lipomata  are  essentially  benign,  and  do  not  demand 
removal  unless  uncomfortable  or  infected. 


^ii;ry~A).^  ^ 


Pig.  90. — Mixed-cell  sarcoma  of  abdominal  wall,  starting  in  a  pig- 
mented mole  near  the  umbilicus.  Two  years  growth.  (Seen  by  courtesy 
of  Dr.  H,  F.  Taylor,  Ridley  Park.  Pa.) 

Sarcoma  starts  usually  from  a  pigmented  mole,  is  usually 
melanosarcoma,  grows  rapidly  and  is  very  malignant.  Early 
removal  and  x-ray  or  radium  offer  the  only  chance,  though  a 
small  one,  of  relief. 


CHAPTER  XII 

INJURIES  OF  THE  BIRTH  CANAL,  AND 
THEIR  REPAIR 

CLASSIFICATION  OF  INJURIES 

I.  Injuries  to  the  Pelvis. — (i)  Fracture  or  separation  of 
the  symphysis;  (2)  fracture  or  separation  or  sprain  of  the 
sacro-ihac  joints;  (3)  fracture  of  ramus  of  pubes;  (4)  fracture 
of  coccyx. 

II.  Rupture  of  the  Uterus. — (i)  Complete;  (2)  incom- 
plete. 

III.  Lacerations  of  the  Cervix. — (i)  Unilateral  (open  or 
submucous):  (2)  bilateral  (open  or  submucous);  (3)  stellate 
(open  or  submucous) ;  (4)  annular  detachment. 

IV.  Lacerations  of  Anterior  Vaginal  Wall. — (i)  Clean  cuts 
of  mucous  membrane;  (2)  open  or  submucous  tears  of  muscle 
or  urogenital  trigonum. 

V.  Lacerations  of  the  Perineum. — (i)  Tears  of  the  levator 
ani;  (2)  tears  of  deep  transversus  perinei;  (3)  tears  of 
anterior  and  posterior  layers  of  triangular  ligament;  (4) 
tears  of  the  bulbocavernosus ;  (5)  tears  of  the  superficial 
transversus  perinei;  (6)  Tears  of  sphincter  ani  (complete 
tear). 

Further  divisions  into:  (i)  Complete  tear  (involving  sphincter 
ani);  (2)  incomplete  tear  {not  involving  sphincter);  (3) 
central  perforation  of  the  perineum;  (4)  laceration  and 
abrasion  of  labia. 

VI.  Fistulas. — (i)  Vesicovaginal  (on  anterior  vaginal  wall); 
(2)  uretero vaginal  (in  vaginal  fornix) ;  (3)  rectovaginal 
(on  posterior  vaginal  wall). 

228 


LACERATIONS    OF   THE    CERVIX  229 

INJURIES  TO  THE  PELVIS 

Recent  injuries  of  the  pelvic  bones,  except  fracture  of  the 
coccyx,  are  complications  of  the  puerperium,  and  hence 
belong  in  works  on  obstetrics.  Relaxation  of  the  sacro-iliac 
joints  gives  great  discomfort,  persisting  often  for  many  months 
after  delivery.  It  is  also  possible  from  sudden  muscular 
exertion  or  strain,  entirely  independent  of  childbirth. 

Symptoms. — (i)  Intense  backache,  aggravated  by  exertion, 
most  marked  over  the  affected  joint;  (2)  inability  to  sit  long 
in  any  position;  (3)  difi&culty  on  arising  from  bed  or  chair; 
(4)  occasionally  so  severe,  if  bilateral,  as  to  make  walking 
impossible. 

Treatment.- — A  binder  of  unyielding  material  like  heavy 
muslin  or  light  canvas,  laced  tight  over  the  hips  to  immobilize 
the  joint;  in  moderate  cases,  lacing  the  lower  third  of  the 
ordinary  corset  gives  sufficient  relief.  The  binder  is  worn 
constantly,  except  in  bed,  and  is  put  on  before  the  patient 
arises  in  the  morning. 

Recovery  is  slow,  usually  four  to  six  months  being  required, 
and  the  condition  returns  in  subsequent  pregnancies. 

Fracture  of  the  coccyx  is  discussed  in  Chapter  XIII,  under 
the  sequelae  of  childbirth. 

RUPTURE  OF  THE  UTERUS 

Rupture  of  the  uterus  is  purely  an  obstetrical  accident,  and 
needs  no  discussion  here. 

LACERATIONS  OF  THE  CERVIX 

Causes.— (i)  Childbirth  (by  far  the  commonest);  (2) 
forcible  dilatation;  (3)  passage  or  extraction  of  large  sub- 
mucous fibroids. 

Forceps  delivery  accounts  for  the  greatest  number.  The 
cervix  is  always  torn  if  the  forceps  is  applied  before  the 
head  has  passed  through  the  cervical  ring. 

Kinds. — (i)  Unilateral;  (2)  bilateral;  (3)  stellate;  (4)  an- 
nular detachment. 


230 


INJURIES   OF   THE  BIRTH    CANAL 


A  unilateral  tear  involves  only  one  side  of  the  cervix. 
This  type  often  heals  spontaneously,  does  not  cause  eversion 
(because  the  uninjured  side  acts  as  a  splint),  and  not  in- 
frequently causes  no  erosion. 

A  bilateral  tear,  involving  both  sides  and  usually  more 
extensive  on  one  side  than  the  other,  always  causes  eversion 
and  erosion,  and  is  the  commonest  type  of  cervical  tear. 

A  stellate  tear  means  a  tear  in  three  or  more  directions, 


Pig.  91. — I.  Unilateral  laceration  of  the  cervix.  2.  Bilateral  lacera- 
tion of  the  cervix.  3.  Stellate  laceration  of  the  cervix.  As  seen  through 
a  speculum. 

usually  bilateral  with  a  vertical  split  in  the  anterior  lip. 
This  type  causes  eversion,  erosion  and  hypertrophy. 

Annular  detachment  is  of  no  importance  in  gynecologic 
work.  The  cervix,  partially  dilated,  has  been  torn  off  in 
labor,  and  unless  tabs  of  tissue  are  left,  the  circular  wound 
has  healed  and  requires  no  repair. 

Terminations. — (i)  Spontaneous  healing,  which  is  uncom- 
mon, except  in  unilateral  tears,  though  it  may  occur  in  the  most 
extensive  stellate  ones;  (2)  eversion  of  the  lips,  where  they 


LACERATIONS    OF    THE   CERVIX  23 1 

are  rolled  apart  and  gape  widely;  (3)  erosion,  a  prolapse 
of  the  red  columnar  epithelium  of  the  cervical  canal  over 
the  squamous  epithelium  of  the  portio;  the  condition 
erroneously  called  "ulceration;"  (4)  hypertrophy  of  the 
cervical  tissue,  most  marked  of  the  anterior  lip,  and  a  constant 
accompaniment  of  prolapse;  (5)  Nabothian  cysts;  small 
pearly  cysts,  containing  clear  mucus,  showing  on  the  vaginal 
portion  of  the  cervix  and  due  to  occlusion  of  the  mouths  of 
the  glands:  (6)  as  a  late  development,  carcinoma.  (For 
details  of  all  these,  see  Chapter  VI.) 

Consequences  of  cervical  tears,  in  addition  to  those 
mentioned  above  are:  (i)  leukorrheal  discharge — profuse 
thick  stringy  mucopus;  (2)  sterihty- — either  from  changed 
cervical  secretions  or  stenosis  of  the  internal  os;  (3)  menor- 
rhagia — from  uterine  congestion;  (4)  multiple  miscarriages. 

Symptoms.^ — (i)  Leukorrhea,  of  the  cervical  type,  very  pro- 
fuse; (2)  pelvic  discomfort,  if  the  scar  tissue  extends  in  the 
vaginal  vault;  (3)  dyspareunia,  for  the  same  reason;  (4) 
menorrhagia  usually,  and,  if  there  is  marked  erosion,  often 
metrorrhagia;  (5)  reflex  symptoms  (backache,  hysteric  neu- 
roses, headache,  etc.)  of  doubtful  value  and  obscure  cause. 

The  only  constant  symptom  is  leukorrhea.  Profuse  muco- 
purulent discharge,  sufflcient  to  require  a  napkin  for  pro- 
tection, in  a  patient  who  has  had  a  child  and  is  free  from  gonor- 
rhea, is  practically  always  due  to  lacerated,  eroded  cervix. 

Diagnosis. — (i)  Digital  examination  is  unreliable.  The 
scar  of  a  healed  tear  feels  astonishingly  like  an  open  one;  (2) 
a  bivalve  speculum  should  always  be. used,  and  the  diagnosis 
is  made  by  it  only. 

It  is  often  very  difficult  to  diagnose  between  a  badly  eroded 
cervix  and  early  carcinoma.  Both  bleed  easily  to  the  touch, 
and  in  any  case  in  the  least  suspicious,  a  piece  must  be  excised 
for  microscopic  diagnosis. 

If  the  tear  has  been  extensive  and  involves  the  vaginal  vaults, 
the  resulting  immobihty  of  the  uterus  is  very  like  that  of  sal- 
pingitis with  extensive  adhesions. 


232 


INJURIES    or    THE   B-IRTH   CANAL 


Treatment 

Palliative  treatment  is  useless  for  a  cervical  tear;  while 
erosion  can  be  temporarily  diminished,  it  recurs  as  soon  as 
treatment  is  stopped.  The  only  treatment  is  (i)  repair 
or  (2)  amputation. 

Choice  of  Method. — It  is  difl&cult  to  lay  down  a  dogmatic 
rule,  and  each  case  must  be  judged  on  its  merits;  but  as  a 
general  thing  it  is  safe  to  say  that  unilateral  and  bilateral  tears, 
without  hypertrophy,  can  be  repaired,  while  stellate  tears 
and  hypertrophy  of  the  cervix  require  amputation. 

Cicatricial  bands  often  form  from  the  side  of  the  cervix  to 


Pig.  92. — I.  The  method   of   denudation   and   placing   the   stitches   for 
Emmet's  trachelorrhaphy.     2.   The  repair  completed. 

the  vaginal  vault.  They  are  usually  raised  ridges  of  dense 
scar  tissue,  but  may  be  actual  circular  bands.  They  should 
be  excised  before  any  repair  is  attempted. 

Repair  of  the  cervix  (Emmet's  trachelorrhaphy)  is  one  of 
the  few  operations  in  gynecology,  if  not  the  only  one,  still 
done  in  its  original  form,  and  never  improved  upon,  except  for 
the  kind  of  suture  material. 

Technic. — (i)  The  patient  is  anesthetized  and  prepared  as 
for  any  vaginal  operation. 

2.  The  anterior  and  posterior  lips  of  the  cervix  are  caught 
with  tenacula,  pulled  down  and  separated. 


LACERATIONS    OF   THE   CERVIX  233 

3.  The  edges  of  the  denudation  are  marked  out,  as  in  the 
diagram,  care  being  taken  to  limit  the  denudation  to  the  area 
of  the  laceration  and  not  to  encroach  upon  the  cervical  canal. 
The  shape  oi:  the  denudation  is  triangular,  on  each  lip. 

4.  Interrupted  stitches,  of  number  3  forty-day  chromic  catgut 
are  placed,  beginning  on  the  mucous  membrane  of  the  vaginal 
aspect  of  the  anterior  lip,  emerging  close  to  the  mucous  mem- 
brane of  the  cervical  canal,  entering  again  close  to  the  edge  of 
the  mucous  membrane  of  the  canal  on  the  posterior  lip,  and 
emerging  on  the  vaginal  aspect  of  the  posterior  lip,  opposite  the 
point  of  entrance  on  the  anterior  lip.  Three  or  four  sutures  to 
a  side  are  required. 

5.  The  stitches  are  tied,  after  all  are  inserted. 

Care  should  be  taken  not  to  close  the  canal  too  tightly. 
When  all  stitches  are  tied,  the  cervical  canal  should  have  a 
caliber  of  a  number  17  French  sound,  otherwise  there  may  be  a 
secondary  dysmenorrhea.  If  the  tear  is  unilateral,  only  one 
side  is  denuded  and  repaired. 

At  times  an  accurate  repair  of  a  bilateral  tear  may  be  pre- 
vented by  hypertrophy  of  the  mucous  membrane  of  the  canal. 
A  wedge-shaped  exsection  of  the  mucosa  will  obviate  the 
difficulty  and  avoid  amputation  of  the  cervix.  A  repaired 
cervix  never  withstands  subsequent  childbirth  and  is  sure  to 
tear  again. 

Amputation  of  the  cervix  is  best  done  by  the  Hegar  method, 
as  no  other  gives  such  uniform  accurate  coaptation  of  the 
edges  of  the  wound. 

Indications.' — ("i)  Stellate  tears;  (2)  hypertrophy  of  the  cer- 
vix, (3)  very  extensive  tears,  unilateral  or  bilateral,  involving 
the  vaginal  vaults;  (4)  severe  endocervicitis  with  marked 
erosion  and  excessive  leukorrhea;  (5)  in  all  cases  of  prolapse 
of  the  uterus. 

Advantages.' — (i)  It  allows  a  neater  coaptation  of  the  wound 
edges,  in  the  cases  where  it  is  indicated;  (2)  leukorrheal  dis- 
charge is  greatly  lessened;  (3)  it  withstands  subsequent  child- 
birth much  better  than  repair. 


234 


INJURIES    OF    THE   BIRTH    CANAL 


Disadvantages.- — (i)  Danger  of  secondary  cervical  stenosis 
and  dysmenorrhea;  (2)  tendency  to  repeated  miscarriage,  if 
the  cervix  is  amputated  high;  (3)  unnecessary  if  a  neat  result 
can  be  obtained  by  repair,  which  is  both  quicker  and  easier. 

Technic  of  Amputation. — (i)  The  patient  is  in  the  dorsal  posi- 
tion, prepared  as  for  any  vaginal  operation  and  anesthetized. 

2.  The  anterior  and  posterior  lips  of  the  cervix  are  caught  by 
tenacula. 

3.  A  circular  incision  is  made  around  the  cervix,  to  free  the 
vaginal  walls  at  their  attachments. 


Fig.   93. — Hegar's  amputation  of  the  cervix. 

4.  The  cervix  is  amputated  as  a  cone,  and  any  actively 
bleeding  points  (usually  few)  tied  with  number  o  plain  catgut. 

5.  With  heav}^  curved  needle,  armed  with  number  3  chromic 
(40-day)  catgut,  the  sides  of  the  cervix  are  repaired,  taking  the 
anterior  vaginal  mucosa,  the  muscle  of  the  cervix  and  the 
posterior  vaginal  mucosa.  Two  interrupted  stitches  are  placed 
on  either  side  of  the  cervical  canal;  none  are  tied  as  yet. 

6.  With  the  same  needle  and  similar  catgut,  two  interrupted 
stitches  are  placed  in  each  lip,  in  the  middle  line,  emerging  in 
the  cervical  canal,  so  as  to  make,  when  tied,  a  new  external  os. 

7.  All  the  stitches  are  now  tied,  the  lateral  ones  first,  then 


LACERATIONS    OF   THE   ANTERIOR  VAGINAL   WALL         235 

those  forming  the  anterior  Hp  of  the  new  external  os  and  then 
the  posterior. 

8.  If  any  extra  stitches  are  required  to  secure  perfect  coapta- 
tion they  are  inserted  after  the  others  are  tied.  The  cervical 
canal  should  be  about  17   (French  scale)  in  caliber. 

After  either  repair  or  amputation  of  the  cervix,  patients 
should  remain  in  bed  for  one  or  two  weeks,  depending  upon 
whether  other  plastic  work  was  done  at  the  same  time.  Coitus 
should  be  forbidden  for  at  least  two  months.  If  secondary 
stenosis  results,  the  canal  can  be  dilated,  as  an  office  procedure, 
by  steel  bougies,  under  strict  asepsis. 

Dates  of  Repair.- — ^Like  any  other  plastic  operation,  these 
may  be  primary  (within  forty-eight  hours  of  injury);  inter- 
mediate (two  to  fourteen  days  after  injury)  or  secondary  (after 
fourteen  days).  The  first  two  are  concerned  with  the  puer- 
perium  only.  The  secondary  repair  is  the  usual  gynecologic 
operation. 

LACERATIONS  OF  THE  ANTERIOR  VAGINAL  WALL 

Lacerations  of  the  anterior  vaginal  wall  are  (i)  clean  cuts  of 
the  mucous  membrane  (of  importance  only  directly  after  de- 
livery, because  of  bleeding);  (2)  laceration  of  the  muscle  and 
fascia  of  the  urogenital  trigonum;  (3)  vesicovaginal  fistula. 

Causes. — (i)  Injuries  of  childbirth,  almost  exclusively. 

2.  Very  rarely,  the  passage  of  a  submucous  fibroid,  large 
enough  to  simulate  the  mechanism  of  delivery  of  a  fetal 
head. 

Muscle  of  the  Urogenital  Trigonum.^This  is  the  analogous 
muscle  to  the  compressor  urethras  in  the  male.  It  arises  at  the 
junction  of  the  symphysis  and  descending  ramus  of  the  pubis, 
and  runs  diagonally  back  above  the  anterior  vaginal  wall. 
It  divides  and  joins  its  fellow  from  the  opposite  side  above 
and  below  the  urethra,  inserting  into  the  fascia  of  the  anterior 
vaginal  wall.  It  is  the  only  direct  muscular  support  possessed 
by  the  lower  third  of  the  anterior  vaginal  wall,  to  which  it 
is  a  levator,  and  acts  as  a  compressor  urethrae.     A  tear  of 


236 


INJURIES    OF    THE  BIRTH   CANAL 


this  muscle  is  one  of  the  factors  in  the  production  of  a  cystocele, 
and  also  accounts  for  many  cases  of  incontinence  of  urine  in 
later  years. 

Diagnosis  of  Injury. — With  the  patient  in  the  dorsal  position, 
the  forefinger  of  one  hand  is  inserted  in  the  vagina,  and 
pressure  made  straight  up,  to  either  side  of  the  urethra,  against 
the  lower  edge  of  the  pubic  bone.  If  the  muscle  is  torn,  the 
finger  presses  against  the  sharp  edge  of  the  bone.  If  it  is 
not  torn,  a  flat  ribbon  of  muscular  tissue  and  fascia  is  felt 

between  the  finger  and  the 
bone.  On  inspection,  the 
lower  portion  of  the  anterior 
vaginal  wall  bulges  down- 
ward, if  the  muscle  is  torn. 

Consequences  of  lacera- 
tion are:  (i)  Cystocele;  (2) 
urethrocele;  (3)  inconti- 
nence of  urine  on  effort, 
such  as  sneezing,  coughing, 
etc. 

Technic  of  Repair. — (i) 
Dorsal  position,  usual  prep- 
aration and  anesthesia. 
2.  The  anterior  vaginal 
wall  is  caught  by  a  double  tenaculum,  just  to  the  outer  side  of 
the  urethra. 

3.  A  second  tenaculum  catches  the  labium  on  the  same  side, 
at  the  same  level. 

4.  When  these  are  separated,  a  triangular  sulcus  is  seen  on 
the  lateral  aspect  of  the  anterior  vaginal  wall,  with  the  point 
toward  the  cervix. 

5.  This  sulcus  is  denuded  and  the  muscle  repaired  with  a 
continuous  tier  stitch  of  number  i  forty-day  chromic  cat- 
gut. 

Interrupted  sutures  can  be  used,  but  the  continuous  is 
quicker  and  better. 


Pig.   94. — Repair  of  the  muscle  and 
fascia  of  the  urogenital  trigonum. 


TEARS    or   THE    POSTERIOR  VAGINAL    WALL  237 

VESICOVAGINAL  HSTULA 

'    Vesicovaginal  fistula  is  discussed  in  Chapter  XV  on  Genital 
Fistulas. 

TEARS  OF  THE  POSTERIOR  VAGINAL  WALL  AND 
PERINEUM 

As  perineal  tears  are  almost  invariably  the  result  of  child- 
birth, and  as  practically  all  of  them  admit  of  repair  during 
the  puerperium,  the  subject  is  considered  here  from  the 
obstetrical  as  well  as  the  gynecologic  standpoint.  Were  all 
patients  properly  repaired  after  delivery,  the  need  for  any 
plastic  operation  at  a  later  date  would  be  nearly  eliminated. 

The  great  majority  of  patients  who  have  had  children  have 
some  degree  of  perineal  tear.  The  degrees  of  tear  are  vari- 
ously classified,  the  more  common  division  being  (i)  first- 
degree  tears,  involving  only  the  tissues  of  the  perineal 
body  in  the  middle  line;  (2)  second-degree  tears,  involving  the 
levator  ani  and  (3)  third-degree  tears,  involving  the  sphincter 
ani. 

Lacerations  of  the  vulva  and  labia  are  really  only  abrasions. 
They  are  rarely  deep,  and  unless  attended  by  bleeding,  do 
not  require  sutures. 

Tears  of  the  Vagina,  Pelvic  Floor  and  Perineum. — The  struc- 
tures injured  are:  (i)  Levator  ani  (the  main  muscular  support 
of  the  pelvic  floor;  (2)  deep  trans  versus  perinei — torn  in  the 
middle  line,  and  retracting  to  either  side;  (3)  the  fascia  anterior 
and  posterior  to  the  deep  transversus  perinei — the  anterior 
and  posterior  layers  of  the  triangular  ligament;  (4)  the  super- 
ficial transversus  perinei;  (5)  the  bulbocavernosus;  (6)  the 
sphincter  ani,  if  the  tear  extends  that  far  in  the  middle  line. 

Tears  of  the  levator  ani  are  two  kinds :  (i)  Forceps  cuts,  which 
may  be  anywhere  in  the  course  of  the  muscle  and  are  usually  a 
more  or  less  complete  division  at  right  angles  to  the  fibers 
and  (2)  spontaneous  tears,  in  which  the  muscle  tears  loose 
from  its  tendinous  attachment  to  the  descending  ramus  of  the 
pubes,  and  tears  obliquely  downward  across  the  fibers  of  the 


238  INJURIES    OF   THE   BIRTH   CANAL 

muscle,  but  not  through  them,  so  that  the  tear  opens  out  as 
a  book  is  opened,  when  stood  upon  its  back.  This  muscle  is 
the  main  support  of  the  pelvic  floor,  and  its  injuries  are 
attended  by  the  well-known  effects  of  such  a  tear;  sense  of 
loss  of  support,  rectocele,  and  later  prolapse  of  the  uterus. 

The  tear  may  be  either  open  or  submucous;  the  open  tears 
are  easy  to  see  and  feel,  the  submucous  tears  are  often  over- 
looked and  result  later  in  the  misnamed  "relaxation  of  the 
pelvic  floor." 

Causes  of  Perineal  Tears.^ — (i)  Spontaneous  delivery;  (2) 
forceps  (almost  invariably  cause  a  tear);  (3)  hurried  delivery; 
(4)  posterior  shoulder  of  child  will  often  make  or  extend  a 
laceration;  (5)  contracted  pelvis — the  narrow  pubic  arch 
forcing  the  head  posteriorly;  (6)  occipitoposterior  positions;  (7) 
edema  from  prolonged  labor;  (8)  rigidity. 

In  multiparae,  who  have  been  properly  repaired,  it  is  common 
for  the  perineal  body  to  give  way,  in  subsequent  labors,  but 
re-injuries  of  the  levator  are  much  less  common. 

Symptoms  of  a  Perineal  Tear. — Tears  of  the  first  degree,  in- 
volving for  a  short  distance  only  the  central  perineal  body, 
often  cause  no  syrnptoms  at  all. 

Tears  involving  the  levator  ani  cause  the  following:  (i)  Sense 
of  loss  of  support,  "as  if  everything  were  dropping  out;" 
(2)  this  sensation  is  aggravated  by  standing  or  exertion,  and 
at  the  menstrual  periods;  (3)  backache;  (4)  often  the  pro- 
trusion of  a  rectocele,  referred  to  usually  by  the  patient  as 
"falling  of  the  womb;"  (5)  if  a  rectocele  is  present,  the  patient 
often  has  difficulty  in  defecation. 

All  these  symptoms  are  much  more  marked  if  there  is  an 
associated  retroversion;  even  extensive  tears  may  cause  very 
slight  sjonptoms  if  there  is  no  backward  displacement  of  the 
uterus. 

Diagnosis. — The  patient  is  placed  across  the  bed,  in  the 
dorsal  position.  (2)  She  is  asked  to  strain,  when  the  degree  of 
gaping  of  the  labia  is  noted.  (3)  After  careful  cleansing  of  the 
vulva,  the  labia  are  separated,  when  any  obvious  tear  can  be 


TEARS   OF  THE  POSTERIOR  VAGINAL  WALL 


239 


seen.  (4)  The  thickness  of  the  perineal  body  is  palpated  by- 
one  gloved  finger  in  the  vagina  and  the  thumb  outside,  on  the 
perineum.  This  will  disclose  injury  to  the  bulbocavernosus, 
superficial  and  deep  transversus  perinei  muscles.  (5)  The 
levator  ani  is  tested  as  follows :  the  forefinger  is  inserted  in  the 
vagina,  up  to  the  second  joint,  and  pressed  downward  and  out- 
ward, to  note  a  cleft,  if  any,  in  the  muscle.  The  forefinger  is 
swept  from  one  pubic  ramus  to  the  other,  to  note  whether  the 
muscle  forms  an  unbroken  horseshoe  curve.  With  the 
forefinger  in  the  vagina  and  the  thumb  outside,  the  thickness 


Pig.  95. — Testing  the  levator  ani  muscle.  The  forefinger  is  inserted 
in  the  vagina  up  to  the  second  joint;  the  thumb  is  midway  between  the 
tuberosity  of  the  ischium  and  the  anus. 

of  the  levator  Is  palpated.  (6)  The  sphincter  ani  is  always 
tested  last,  by  feeling  the  complete  circumference  of  the 
muscle  with  the  forefinger  in  the  rectum  and  the  thumb  outside. 
It  is  easy  to  overlook  a  submucous  tear  of  the  sphincter,  and 
a  serious  mistake  to  do  so.  Mere  inspection  of  the  perineum 
is  no  guide  to  the  extent  of  injury  present. 

Results  of  Lacerated  Perineum. — (i)  Rectocele;  (2)  hemor- 
rhoids; (3)  prolapse  of  the  uterus. 


240 


INJURIES    OF   THE  BIRTH   CANAL 


Central  Tear  of  the  Perineum. — In  very  rigid  perinei,  when 
overdistended  by  the  head,  a  circular  perforation  sometimes 
appears  midway  between  the  posterior  commissure  of  the  vulva 
and  the  anus.  This  should  be  at  once  opened  through  into 
the  vagina  by  scissors,  followed  by  a  double  episiotomy.  Unless 
so  treated,  the  head  is  likely  to  emerge  from  the  rectum,  with 
disastrous  results  to  the  sphincter. 

Symptoms  of  Tear  Through  the  Sphincter  Ani  (Complete 
Tear). — (i)  Incontinence  of  gas  and  feces  (which  may  mean 


Fig.  96. — Testing  the  sphincter  ani  for  laceration.     (After  B.  C.  Hirst.) 


only  overstretching  of  the  sphincter);  (2)  the  sphincter  forms  a 
slightly  curved  line  across  the  posterior  border  of  the  anus; 
(3)  its  ends  are  marked  by  two  visible  dimples  or  pits;  (4)  the 
folds  of  skin,  or  rugae,  normally  surrounding  the  anus  are  gone 
anteriorly  and  deepened  posteriorly;  (5)  if  the  sphincter  be 
palpated  with  one  finger  in  the  rectum,  the  gap  in  the  ring 
muscle  can  be  felt  plainly. 

Time  of  Repair. — The  immediate  repair  directly  after  labor 
of  the  perineum  is  not  advised,  for  the  following  reasons:  (i) 
Accuracy  of  diagnosis  is  impossible;  (2)  the  bruised  and  edema- 


TEARS    OF   THE   POSTERIOR  VAGINAL   WALL  24 1 

tous  tissues  are  not  good  material  for  repair;  (3)  the  danger 
of  infection  is  very  much  greater;  (4)  these  repairs  are  often 
only  the  closure  of  the  perineal  skin,  with  entire  disregard 
of  the  muscular  injuries;  (5)  failure  is  common,  necessitating 
a  second  operation  later.  Above  all  does  this  apply  to 
operations  for  complete  tear  of  the  sphincter  ani. 

All  these  disadvantages  can  be  obviated  by  repair  on  the 
seventh  day  after  delivery,  unless  the  patient  has  fever,  in 
which  case  the  repair  is  postponed  until  the  temperature  has 
been  normal  for  a  week.  With  ordinary  care,  sepsis  is  not  to 
be  feared,  and  objections  based  upon  supposed  difficulty  or 
unfavorable  healing  are  not  based  upon  fact. 

Treatment 

Preventive. — Avoidance  of  undue  haste  in  delivery;  protec- 
tion of  the  perineum  by  retarding  the  head;  lack  of  haste  in 
forceps  delivery;  using  small  forceps  (Hale-Sawyer)  whenever 
possible;  episiotomy  when  indicated;  avoidance  of  large  doses 
or  indiscriminate  use  of  pituitrin.  By  observance  of  these 
details,  many,  but  by  no  means  all,  lacerations  can  be  avoided 
or  at  least  limited  in  extent. 

Technic  of  Repair.^ — Immediate:  No  matter  what  the 
physician's  preference  may  be,  this  should  never  be  undertaken 
if  the  vulva  and  vagina  are  badly  bruised;  if  there  is  reason  to 
believe  that  there  is  beginning  infection;  if  the  patient  is 
excessively  exhausted  or  if  she  is  an  eclamptic;  or  if  the 
laceration  dates  from  a  previous  labor.  It  is  not  advisable  to 
place  the  sutures  before  the  placenta  is  delivered,  and  the  old 
practice,  recently  revived,  of  putting  sutures  in  the  perineum 
before  delivery  of  the  head,  and  removing  them,  if  not  needed, 
after  delivery,  is  absurd.  Anesthesia  is  said  not  to  be  needed, 
because  the  overstretched  tissues  are  not  sensitive.  The 
patient's  actions,  while  the  repair  is  in  progress,  will  often 
cause  the  physician  grave  doubts  as  to  the  accuracy  of  this 
statement. 

Technic  of  Immediate  Repair. — (i)  The  patient  is  arranged 
16 


242  INJURIES    OF   THE   BIRTH   CANAL 

across  the  bed,  with  her  feet  on  two  chairs,  and  her  hips  over 
the  edge  of  the  bed. 

2.  The  vulva  is  carefully  cleansed  with  cotton  and  lysol 
solution  (one  dram  to  two  pints). 

3.  If  much  blood  is  trickling  down  from  above,  a  large  gauze 
or  cotton  sponge  may  be  inserted  in  the  vagina,  against  the 
cervix,  and  removed  after  the  stitches  are  in  place,  but  before  they 
are  tied. 

4.  The  labia  are  separated  and  the  extent  of  the  injury 
inspected.  This  is  materially  aided  by  retraction  of  the 
anterior  vaginal  wall  by  an  assistant. 

5.  Visible  open  tears  of  the  levator  may  be  sutured  with  a 
continuous  number  i  chromic  catgut  stitch. 

6.  The  perineal  body  is  repaired  by  interrupted  stitches  of 
number  3  chromic  catgut  or  silkworm-gut,  placed  so  that  the 
entire  depth  of  the  tear  is  included,  and  not  the  skin  of  the  peri- 
neum only. 

Episiotomy  wounds  are  sutured  in  the  same  way.  Plain 
catgut  is  not  to  be  used,  as  it  disappears  too  Soon.  Silk  has  the 
disadvantage  of  cutting  through  the  tissues.  The  after-care 
of  these  repairs  is  as  described  under  the  delayed  repair  of  the 
perineum.  The  silkworm-gut  sutures  are  removed  on  the 
twelfth  day.  The  catgut  ones  will  disappear  spontaneously. 
The  sphincter  ani  may  be  repaired  immediately,  if  torn,  but 
much  better  results  are  attained  by  delaying  the  repair  for 
at  least  a  week.  If  the  repair  is  undertaken  at  once,  it  is  done 
as  described  in  the  delayed  repair. 

Technic  of  the  Delayed  Repair  of  the  Perineum. — Prepara- 
tion for  Operation:  Day  before  operation:  4  p.m.  Shave  pubes 
completely,  g  p.m.  Magnesium  sulphate  3^^  ounce,  or  citrate 
of  magnesia,  flat,  8  ounces. 

Day  of  Operation. — Early  in  the  morning,  cup  of  beef  tea,  no 
other  breakfast.  Clear  lower  bowel  out  thoroughly  by  re- 
peated enemas,  so  that  last  enema  is  given  at  least  two  hours 
before  operation.  Continue  enemas  until  water  returns  clear. 
Two  hours  before  operation  give  paregoric  13^^  teaspoonfuls. 


TEARS    OF    THE    POSTERIOR   VAGINAL    WALL  243 

This  inhibits  peristalsis  much  better  than  morphin.  Cathe- 
terize  just  before  etherization. 

Do  not  give  hypodermic  of  morphin  and  atropin.  The 
paregoric  takes  its  place. 

Local  preparation  done  on  the  table,  by  careful  and  complete 
scrubbing  of  vulva  and  vagina  by  cotton  pledgets  and  tincture 
of  green  soap  and  hot  water. 

Choice  of  Operation. — Of  the  multitude  of  operations  de- 
scribed for  perineorrhaphy,   there  are  three  that  answer  all 


e  /         \,  e 


Pig.  97. — The  Emmet  and  Hegar  denudations  compared.  a, 
Lowest  myrtiform  caruncle,  the  same  in  both  operations;  b,  tip  of 
rectocele;  c,  highest  point  in  Hegar  operation  on  posterior  vaginal 
wall;  d,  lines  of  Emmet  denudation;  e,  lines  of  Hegar  denudation.  The 
solid  lines  show  the  shape  of  the  Emmet  denudation;  the  dotted  lines 
that  of  the  Hegar. 

requirements,   provided    the   special   indications   of  each  are 
considered. 

(i)  The  Emmet  operation,  satisfactory  in  moderate  tears, 
with  slight  rectocele,  but  unsatisfactory  if  the  rectocele  is  large 
and  worthless  in  prolapse  of  the  uterus;  (2)  the  Hegar  opera- 
tion, of  value  in  large  rectocele  and  prolapse,  but  unneces- 
sarily extensive  in  moderate  tears;  (3)  the  B.  C.  Hirst  ana- 
tomical restoration,  designed  to  repair  the  various  muscles 
in  the  lines  of  their  original  injuries.     It  is  done  with  the  Em- 


244 


INJURIES    OF   THE  BIRTH   CANAL 


met  denudation  if  there  is  not  much  rectocele;  though  the 
Hegar  denudation  if  there  is. 

The  Emmet  operation  denudes  the  lateral  vaginal  sulci 
separately  and  repairs  them ;  the  Hegar  makes  one  large  central 
triangular  denudation  and  joins  the  levator  of  one  side  to  the 
levator  of  the  other,  above  the  rectum  which  is  crowded  back 
in  the  process.  Hence  the  Hegar  operation  overcorrects  and 
narrows  the  vagina;  the  Emmet  does  not. 

Emmet  Operation. — (i)  The  patient  is  in  the  dorsal  position, 


Fig.   98. — The  Emmet  perineorrhaphy.      {After  Stewart.) 


the  vagina  carefully  cleansed  with  tincture  of  green  soap,  hot 
water  and  lysol  solution. 

2.  As  nearly  all  lochial  discharge  contains  pathogenic  organ- 
isms, the  uterus  should  be  washed  out  with  lysol  solution,  and 
a  large  pledget  of  cotton  soaked  in  lysol  solution  placed  against 
the  cervix.  This  must  always  be  removed  as  soon  as  the 
operation  is  completed.  In  secondary  operations,  long  after 
childbirth,  this  step  is  of  course  omitted. 

3.  Each  labium  is  caught  with  a  bullet  forceps  just  below 
the  lowest  myrtiform  caruncle  (above  which  is  the  duct  of 


TEARS   or   THE  POSTERIOR  VAGINAL  WALL 


245 


Bartholin's  gland)  or  more  conveniently  the  labia  are  sepa- 
rated with  the  Gelpi  self-retaining  perineal  retractor. 
4.  The  tip  of  the  rectocele  is  caught  with  a  volsellum  (the 

d    d  c     c 

1a  I,  ^-'' 


r 

e  e 

99- — Diagram  of  the  Emmet  perineal  repair,  a,  Denuded  area; 
h,  area  not  denuded;  c,  interrupted  stitches  in  sulcus;  d,  continuous 
stitches  in  sulcus;  e,  crown  stitches. 


Pig. 


Pig.  100. — The  Gelpi  self-retaining  perineal  retractor,  for  use  in 
plastic  operations.  It  is  especially  useful  where  one  has  only  one 
assistant. 

tip  is  the  portion  nearest  the  cervix,  in  the  midline,  which 
without  tension  can  be  brought  down  to  the  posterior  commis- 
sure of  the  vulva). 

5.  The  lateral  sulci  are  denuded  in  one  piece  or  in  strips. 


246 


INJURIES    OF   THE  BIRTH   CANAL 


6.  The  central  perineal  triangle  is  denuded,  and  if  any 
granulation  tissue  is  present,  itds  curetted  off  with  the  edge  of 
a  knife. 

7.  The  lateral  sulcus  wounds  are  closed  by  continuous  or 
interrupted  sutures  of  number  i  chromic  catgut,  or  interrupted 
sutures  of  silkworm-gut.  Catgut  stitches  are  tied,  silkworm- 
gut  are  secured  with  perforated  shot,  as  it  makes  their 
removal  easier. 

8.  The  crown  stitches 
of  number  i  chromic  cat- 
gut or  silkworm-gut  are 
inserted.  The  stitch  passes 
through  one  labium,  just 
below  the  tenaculu  m, 
emerges  in  the  sulcus  just 
below  the  last  sulcus  stitch, 
transfixes  the  tip  of  the 
rectocele,  and  passes 
through  the  other  labium 
to  emerge  on  the  skin  per- 
ineum, just  opposite  its 
point  of  insertion.  Two  or 
three  of  these  stitches  are 
required.      They    are     tied 

from  above  downward,  after  all  are  inserted. 

9.  The  vagina  is  douched  and  packed  with  sterile  gauze. 
Hegar  Operation. — (i)  The  patient  is  prepared  as  for  the 

Emmet  operation. 

2.  The  labia  are  caught,  as  in  the  Emmet  operation. 

3.  A  point  in  the  middle  of  the  posterior  vaginal  wall,  about 
two-thirds  of  the  way  from  the  vulva  to  cervix,  is  caught  with 
a  volsellum. 

4.  The  large  single  triangle  formed  by  these  three  instruments 
is  denuded,  care  being  taken  to  avoid  wounding  the  rectum, 
an  accident  likely  to  occur  unless  great  care  is  exercised. 
Any  granulation  tissue  in  the  area  to  be  denuded  is  curetted  off. 


Fig.  ioi. — The  Hegar  perineorrhaphy. 


TEARS    or    THE   POSTERIOR  VAGINAL   WALL 


247 


5.  Transverse  interrupted  stitches  are  placed  across  this 
triangle  from  the  apex  downward.  The  upper  ones  may  be  of 
number  3  chromic  catgut,  the  lower  three  vaginal  and  the 
perineal  stitches  should  be  silkworm  -gut,  because  they  are 
under  considerable  tension. 

6.  The  perineal  stitches  are  placed,  beginning  with  the  one 
nearest  the  anus,  so  as  to  close  the  wound  in  the  perineal  body, 


f    r   r  f 


Fig.  102. 


Fig.  103. 


Pig.  102. — Denudation  in  the  Hegar  operation,  and  suture  of  the 
rectocele  above  the  levator  ani.  a,  Myrtiform  caruncles;  h,  denuded 
area;  everything  included  in  triangle  is  denuded;  c,  stitch  puckering  up 
tip  of  triangle. 

Pig.  103. — Hegar  operation,  second  stage,  a,  Myrtiform  caruncles; 
6,  denuded  area;  c,  puckered  up  tip  of  triangle;  e,  interrupted  stitches 
of  levator  ani;  /,  interrupted  suture  of  perineal  body. 


entering  from  and  emerging  in  the  perineal  skin,  and  are  tied 
from  above  downward. 

7.  The  vagina  is  douched  and  packed  with  sterile  gauze. 
The  Hegar  operation  disregards  the  normal  perineal  anatomy 
and  its  injuries  but  is  a  satisfactory  operation  in  the  cases  where 
it  is  indicated. 

Technic  of  the  B.  C.  Hirst  Perineorrhaphy. — (i)  The  patient 
is  prepared  as  for  the  Emmet  operation. 


248  INJURIES    or    THE  BIRTH   CANAL 

2.  The  labia  and  tip  of  the  rectocele  are  caught  as  in  the 
Emmet  operation. 

3.  The  sulci  and  central  triangles  are  denuded  as  in  the 
Emmet  operation. 

4.  The  fascia  covering  the  levator  ani  is  incised,  on  each 
side,  in  a  line  parallel  to  and  just  beneath  the  edge  of  the 
sulcus  denudation. 

5.  The  tear  in  the  levator  ani  is  closed  on  each  side,  inside 
the  sheath  of  the  muscle,  by  a  continuous  stitch  of  number  i 
chromic  catgut. 

6.  Two  interrupted  stitches  are  placed  through  the  sheath 
and  end  of  the  deep  transversus  perinei  muscle,  but  are  not 
tied.  The  stitches  pass  through  the  sheath  and  muscle  of 
one  side,  pick  up  the  perineal  body  floor  in  the  middle  line, 
between  the  anterior  and  posterior  layers  of  the  triangular 
ligament,  and  through  the  sheath  and  muscle  of  the  other 
side. 

7.  The  posterior  layer  of  the  triangular  ligament  is  closed 
over  the  bulging  rectum,  it  being  through  the  tear  in  the 
ligament  that  the  rectocele  protrudes. 

8.  The  lateral  sulci  are  closed  in  the  Emmet  operation,  by 
a  continuous  stitch. 

9.  The  tip  of  the  rectocele  is  fastened  down  to  the  posterior 
column  of  the  vagina,  inside  the  posterior  commissure  of  the 
vulva,  where  it  originally  belongs. 

10.  The  tension  of  the  Gelpi  retractor  is  relaxed,  and  the  two 
stitches  securing  the  deep  transversus  perinei  are  tied. 

11.  The  tears  of  Colles  fascia,  bulbocavernosus,  superficial 
transversus  perinei  and  anterior  layer  of  the  triangular  liga- 
ment, all  in  the  perineal  body,  are  closed  by  interrupted  stitches 
placed  so  that,  when  tied,  the  knots  will  be  covered  in  when 
the  perineal  skin  is  closed. 

12.  The  perineal  skin  is  closed. 

13.  The  vagina  is  douched  and  packed  with  sterile  gauze. 
All  catgut  used  is  number  i  chromic  catgut,  of  forty-day 

durability,  except  in  the  skin  sutures,  where  overchromicized 


TEARS   OF   THE  POSTERIOR  VAGINAL  WALL  249 

number  i  gut,  of  greater  durability,  is  used.  This  operation 
is  designed  to  correct  the  lacerations  in  the  planes  in  which 
they  occur,  and  to  effect  a  normal  anatomical  restoration. 

No  perineal  operation  should  be  attempted  from  a  written 
description.  For  its  understanding,  actual  demonstrations 
are  necessary.  It  is  not  usually  advisable  in  recent  injuries 
to  put  in  any  vaginal  packing,  as  it  tends  to  dam  back  the 
lochia.  This  applies  only  to  operations  done  immediately 
after  delivery  or  early  in  the  puerperium. 

Routine  After-care  of  Plastics. — (i)  Morphin  sulph.  gr.  l^, 
atropin  sulph.  gr.  K50  6th  hour  p.r.n. ;  (2)  water  p.r.n.  first 
twenty-four  hours;  (3)  irrigate  perineal  stitches  with  sterile 
water  four  times  daily,  and  also  after  each  urination  or  bowel 
movement,  and  keep  sterile  vulvar  pad  in  place  after  irriga- 
tion; (4)  inspect  stitches  frequently;  if  stitches  are  soiled,  clean 
with  cotton  on  appHcator  and  peroxid  of  hydrogen.  Moder- 
ate cutting  may  be  disregarded;  (5)  vaginal  douche  sterile 
water  every  day  after  fifth  day;  (6)  simple  enema  once  or 
twice  in  second  twenty-four  hours;  (7)  end  forty-eight  hours, 
calomel  gr.  }-^  every  hour  for  six  doses  followed,  2  hours 
after  the  last  dose  by  flat  magnesium  citrate,  6  ounces;  (8) 
soft  diet  after  first  twenty-four  hours,  light  diet  fifth  day,  full 
diet  seventh  day;  (9)  catheterize  8th  hour  p.r.n.;  (10)  take  out 
vaginal  packing  in  twenty-four  hours,  if  any  is  inserted,  and 
note  its  removal  on  the  chart;  (11)  as  a  routine  laxative  use 
compound  cathartic  pills,  one  at  bed  time.  If  too  active, 
give  only  half  a  pill.  If  these  cause  griping,  use  A.  B.  S.  and 
C.  pill. 

Operation  for  Complete  Tear. — Repair  of  a  complete  tear 
should  never  be  attempted  as  long  as  there  is  any  edema, 
sloughing,  unhealthy  granulation,  or  fever.  Failure  is  sure 
if  this  precaution  is  disregarded.  If  a  complete,  or  any  other 
perineal  tear,  shows  sloughing  or  edema,  restoration  to  healthy 
condition  is  more  quickly  attained  by  thrice  daily  douches  of 
hot  sterile  water,  and  application  of  weak  solutions  of  nitrate 
of  silver  (gr.  10  to  oz.  i)  to  any  place  showing  persistent  false 


2SO 


INJURIES    or    THE   BIRTH    CANAL 


membrane.  These  precautions  are  necessary  in  the  puer- 
perium  only. 

Preparation  for  repair  of  complete  tear  is  the  same  as  any 
plastic  operation,  except  that  several  days  must  be  devoted 
to  getting  the  bowels  to  move  freely,  before  the  operation  is 
attempted. 

Technic. — (i)  The  patient  is  arranged  and  cleansed  as  for 
any  plastic  operation. 


Connect,  Tissue  _s . 
Bridge        \ 

Sphincter  — 


C\jsTocele 


Pig.   104. — A  typical  complete  tear  of  the  perineum  through  the  sphincter 
ani.      {After  Graves.) 


2.  The   sphincter   is   stretched  .by   grasping    between    the 
thumbs  and  forefingers,  and  stretched  for  a  full  minute. 

3.  The  labia  and  tip  of  the  rectocele  are  caught  as  in  the 
Emmet  operation. 

4.  An  incision  is  made  from  one  sphincter  pit,  around  the 
tear  in  the  rectovaginal  septum,  to  the  other  sphincter  pit. 

5.  The  rectovaginal  septum  is  spht,  between  the  vagina  and 


TEARS  OF  THE  POSTERIOR  VAGINAL  WALL       25 1 

rectum,  so  as  to  secure  an  ample  margin  of  raw  tissue,  without 
sacrifice  of  any  unnecessary  portion. 

6.  The  tear  in  the  rectovaginal  septum  is  repaired  by  inter- 


PiG.   105. — Arrows     indicate     direction     of     traction.     Stretching     the 
sphincter  ani  in  a  complete  tear  operation. 

rupted  silkworm-gut  stitches,  put  in  from   the  rectal  side,  so 
that  the  knots,  when  tied,  will  be  in  the  rectum. 

Interrupted  chromic  catgut  stitches  with  the  knots  buried 


e 

Fig.  106. — Diagram  for  complete  tear  operation,  a,  Lateral  sulci 
in  vagina  (denuded);  b,  rectocele  (not  denuded);  c,  sphincter  pits;  the 
empty  ends  of  the  sphincter  sheath;  d,  tip  of  tear  in  rectovaginal  septum; 
e,   sphincter  ani,  retracted  in  its  sheath. 

in  the  perineal  body  may  be  used,  but  with  a  greater  likelihood 
of  perineal  fistula. 


252 


INJURIES    OF   THE   BIRTH    CANAL 


7.  The  ends  of  the  sphincter  are  pulled  out  of  the  pits  into 
which  they  had  retracted,  by  single  tenacula,  and  cleared 


Pig.  107. — Bringing  up  the  ends  of  the  sphincter  ani.  The  ends  of 
the  muscle  are  retracted  in  the  sheath,  J:^  to  J^  inch  below  the  surface 
of  the  denudation.      {After  Crossen.) 

of  any  granulation  tissue  which  may  cover  them.     The  sphinc- 
ter may  be  recognized  by  palpation,  noting  that  the  tissue 


Fig.  108. — The  stitches  of  the  complete  tear  operation,  a,  The  tip 
of  the  tear  in  the  rectovaginal  septum;  b,  the  sphincter  ani;  c,  denuded 
area  around  the  tear  in  the  rectovaginal  septum;  d,  end  of  sphincter, 
dug  out  of  its  pit.  I.  Interrupted  suture  closing  apex  of  tear  in  recto- 
vaginal septum.  2.  Interrupted  suture,  through  sphincter  and  sheath. 
Only  one  of  each  kind  is  shown. 


pulled    up   by  the  tenacula  is  continuous  with  the  buried 


TEARS   OF   THE   POSTERIOR  VAGINAL   WALL  253 

part  of  the  muscle,  and  also  by  the  yellowish-red  color 
of  the  exposed  ends.  This  color  is  a  very  marked  contrast 
to  the  much  deeper  red  of  the  surrounding  denudation. 
Two  interrupted  stitches  of  number  i  chromic  catgut 
are  passed  through  the  ends  of  the  muscle,  so  that  when 
tied  the  knots  will  be  buried  in  the  perineal  body.  These 
are  for  approximation  only.  Two  silkworm-gut  stitches  are 
next  passed  through  the  sphincter  and  sheath,  beginning 
at  the  mucocutaneous  junction  at  the  anus  on  one  side, 
and  emerging  at  a  corresponding  point  on  the  opposite  side. 


Pig.   109. — The  sphincter  repaired.     {After  Crossen.) 

These  are  for  approximation  and   tension.     With  this  plan, 
further  tension  stitches  are  unnecessary. 

8.  All  the  rectal  stitches  are  tied  from  above  downward. 

9.  The  rest  of  the  perineal  injury  is  repaired  as  may  be 
required  by  the  extent  of  the  tear,  disregarding  the  rectal 
feature  of  the  tear.  In  complete  tears  it  is  comm.on  for 
the  levator  to  escape  injury,  and  the  tear  is  confined  to  the 
perineal  body  in  the  middle  line. 

After-treatment  is  the  same  as  any  plastic  except  for  the  care 
of  the  bowels.  Much  the  safest  plan  is  to  keep  the  bowels 
liquid  from  the  start,  usually  either  magnesium  citrate  (flat), 
or  Carlsbad  water  and  Sprudel  salts  (one  dram  to  the  tumbler 


254  INJURIES    or   THE  BIRTH   CANAL 

of  water).  Either  of  these  is  used  quantities  varying  in  each 
case,  but  sufficient  to  give  two  Hquid  movements  a  day. 
This  plan  is  much  safer  than  keeping  the  bowels  locked,  and 
infection  is  not  to  be  feared.  The  stitches  are  removed  on 
the  sixteenth  day,  best  in  the  knee-chest  posture  through  a 
rectal  speculum,  cautiousty  opened;  and  the  bowels  must  be 
kept  liquid  for  at  least  a  month  and  soft  for  two  or  three 
months  thereafter.  The  commonest  cause  of  failure,  next  to 
infection,  is  neglect  of  the  bowels. 

Infection  is  likely  to  result  in  either  complete  failure,  or 
rectovaginal  or  rectoperineal  fistula.  These  latter  rarely 
if  ever  heal  spontaneously,  and  must  be  closed  by  a  second 
operation. 

In  this  or  any  other  plastic  it  is  unnecessary  to  keep  the 
knees  bound  together,  unless  the  patient  is  unruly  or  delirious, 
and  she  may  turn  on  either  side  after  twenty-four  hours. 

Factors  Essential  to  Success  in  Complete  Tear  Operations. — 
(i)  Choice  of  proper  time  and  condition  for  operations;  (2) 
stretching  of  the  sphincter;  (3)  exposure  and  cleansing  of  granu- 
lation tissue  from  ends  of  sphincter;  (4)  permanent  suture 
material  (silkworm-gut);  (5)  pass  sutures  deep  enough  to 
catch  sheath  of  sphincter;  (6)  leave  stitches  in  at  least 
sixteen  days;  (7)  keep  bowels  liquid  from  start;  (8)  avoid 
constipation  after  the  stitches  are  removed. 

If  the  bowels  should  be  locked,  the  first  movement  must  be 
secured  under  oil  enemata,  and  in  all  probability  breaking 
up  of  the  fecal  mass  by  the  gloved  finger,  inserted  in  the  anus 
and  morcellating  the  mass  by  pushing  back  toward  the  sacrum 
and  never  forward. 

With  proper  management,  and,  if  necessary,  timely  episi- 
otomy,  a  repaired  sphincter  will  usually  withstand  subsequent 
delivery  without  giving  way. 

Time  in  Bed.  — Silkworm-gut  sutures  in  the  operation  for 
incomplete  tears  are  removed  on  the  twehth  day,  the  patient 
gets  up  on  the  fourteenth  day  and  goes  home  on  the  seventeenth 
day.     In  complete  tears,  the  stitches  are  removed  on  the  six- 


TEARS    OF   THE   POSTERIOR  VAGINAL   WALL  255 

teenth  day,  the  patient  gets  up  on  the  eighteenth  day  and  goes 
home  on  the  twenty-first  day. 

It  has  seemed,  to  the  author,  advisable  to  consider  the  sub- 
ject of  lacerations  of  the  birth  canal  from  the  obstetrical  view- 
point of  the  recent  injury  as  well  as  the  gynecological  one  of 
delayed  repair.  In  no  other  way  can  a  complete  grasp  of  the 
subject  be  gained. 


CHAPTER  XIII 
PATHOLOGICAL  SEQUELS  OF  CHILDBIRTH 

While  many  of  the  conditions  herein  described  can  occur 
from  other  causes,  childbirth  is  responsible  for  them  in  the 
vast  majority  of  cases,  and  hence  this  classification  is  used  for 
convenience. 

The  commonest  pathologic  sequelae  of  childbirth,  injuriously 
affecting  a  patient's  health,  are: 

(i)  Lacerations  of  the  birth  canal;  (2)  retroversion  of  the 
uterus;  (3)  pelvic  inflammation.  These  three  account  for  a 
large  proportion  of  the  ailments  for  which  women  consult 
their  physicians.  The  other  sequelee,  not  arranged  in  order 
of  frequency  are:  (4)  erosion  of  the  cervix;  (5)  diastasis  of  the 
recti;  (6)  floating  kidney;  (7)  fractured  coccyx;  (8)  incontinence 
of  urine;  (9)  relaxed  sacro-iliac  joints;  (10)  rectocele;  (11) 
cystocele;  (12)  prolapse  of  the  uterus;  (13)  genital  fistulae. 

1.  Lacerations  of  the  birth  canal  have  been  described  in 
Chapter  XII. 

2.  Retroversion  of  the  uterus  has  been  described  in  Chapter 
VII. 

3.  Pelvic  inflammation  has  been  described  in  Chapter  VIII. 

4.  Erosion  of  the  cervix  has  been  described  in  Chapter  VI. 

5.  Diastasis  of  the  recti  has  been  described  in  Chapter  XL 

VI.  FLOATING  KIDNEY 

Cause. — (i)  Loss  of  supporting  fatty  capsule;  (2)  drag  on 
kidney  by  movable  cecum  or  colon;  (3)  secondarily  only, 
the  relaxation  of  the  lower  abdomen  by  the  distention  of 
pregnancy. 

Symptoms. — In  most  cases,  symptoms  are  absent.  Only  a 
small  percentage  (5-8  per  cent.)  require  any  relief.     A   dull 

256 


FLOATING   KIDNEY 


257 


dragging  pain  in  the  loin  (nearly  always  the  right)  associated 
with  a  "sense  of  looseness"  in  the  corresponding  side  of  the 
abdomen.  The  discomfort  is  not  transmitted  down  the  ureter, 
as  it  is  likely  to  be  in  stone.  Sudden,  sharp  attacks  of  pain, 
due  to  the  twist  in  the  ureter  with  temporary  hydronephrosis, 
are  common.  Often  a  large  quantity  of  urine  is  passed,  follow- 
ing such  an  attack  of  pain.  The  severity  of  the  symptoms  does 
not  depend  upon  the  degree  of  looseness,  and  coincident 
appendicitis  is  frequent,  due  to  congestion  on  the  appendiceal 


Pig.    1 10. — The  normal  relation  of  the  kidneys,  seen  from  behind. 

veins  by  pressure  of  the  kidney  on  the  mesenteric  veins 
(Edebohls). 

Diagnosis. — The  patient  is  arranged  flat  on  her  back,  with 
knees  flexed  on  the  abdomen.  It  is  impossible,  except  in  thin 
individuals,  to  feel  the  normally  placed  kidney. 

The  left  hand  is  placed  flat  under  the  left  flank,  and  pressed 
upward,  while  the  right  hand  makes  counter  pressure  on  the 
abdomen,  just  below  the  costal  margin.  The  patient  takes  a 
deep  breath  and  then  exhales  quickly.  The  smooth,  elastic 
body  of  the  kidney  is  unmistakable.  As  the  kidney  is  often 
low,  the  examination  should  extend  as  far  down  as  the  pelvic 
brim.  In  doubtful  cases,  the  pelvis  of  the  kidney  may  be 
injected  and  an  a;-ray  will  show  its  position.     Pyelography  is 


258 


PATHOLOGICAL    SEQUELAE    OF    CHILDBIRTH 


not  entirely  safe,  however,  as  extensive  penetration  of  the  silver 
salt  into  the  parenchyma  of  the  kidney  will  sometimes  occur. 
Treatment  is  only  required  when  definite  symptoms  demand 
relief.  Muscular  exercise,  full  diet  and  a  properly  fitting 
abdominal  binder,  with  a  pad,  will  relieve  the  moderate  cases. 
Where  Dietl's  crises  of  pain  occur  however,  or  in  very  low  and 
very  movable  kidneys,  operation  is  required.  The  principle 
is  decapsulation  of  the  kidney,  with  suspension  by  stitches 
through  the  capsule  against  the  cut  edge  of  the  quadratus 
lumborum,  outside  the  erector  spinae,  just  below  the  last  rib. 
The  kidney  should  not  be  fixed  too  high,  above  the  last  rib,  as 


Pig.   III. 


-Nephrorrhaphy. 
sutures. 


Shows  the  method  of  passing  the  fixation 
{Ashton,  after  Edebohls.) 


it  is  likely  to  rotate  over  the  points  of  support.  The  kidney 
thus  fixed,  is  always  palpable,  and  the  patient  should  be  in- 
formed of  this  fact,  to  avoid  errors  of  diagnosis  in  any  future 
examination. 

Technic  of  Edebohls^  Suspensioii  of  Kidney. — (i)  The  skin 
of  the  back  is  prepared  in  the  same  way  as  the  abdomen  for 
section. 

2.  The  patient  is  arranged  lying  on  the  abdomen,  with 
a  cylindrical  air  cushion  under  her  upper  abdomen. 

3.  An  incisipn  is  made  parallel  to  the  outer  border  of  the 
erector  spinae  muscles,  about  three  inches  long. 

4.  The  deep  fascia  is  cut  through  and  the  fatty  capsule  of 
the  kidney  exposed. 


FLOATING    KIDNEY 


259 


5.  By  grasping  the  capsule  with  forceps,  the  kidney  is  gradu- 
ally coaxed  out  of  the  wound.  In  this  step  the  patient's  body 
will  often  have  to  be  pulled  up  or  down  over  the  air  cushion, 
to  bring  the  kidney  into  the  wound. 

6.  The  kidney  should  never  be  turned  transversely  to  hold  it 
in  place  in  the  wound,  but  is  left  as  it  emerges,  parallel  to  the 
axis  of  the  wound. 

7.  The  capsule  is  spht  in  the  middle  line  from  pole  to  pole 
and  is  dissected  back  laterally,  so  the 
kidney  is  completely  decapsulated. 

8.  Four  stitches  of  number  3  chromic 
catgut  (40- day)  are  passed  through  the 
capsule,  one  at  each  corner,  taking 
multiple  bites  to  prevent  tearing  out. 
The  ends  are  left  long  and  caught  in 
hemostats. 

9.  The  air  cushion  is  deflated  and  the 
kidney  returned  to  its  bed  at  the  bottom 
of  the  wound. 

10.  The  ends  of  the  stitches  in  the 
capsule  are  rethreaded  in  needles  and 
passed  through  the  muscle  at  each 
side  of  the  wound,  so  that  raw  edge 
of  muscle  is  turned  against  the  de- 
capsulated surface  of  the  kidney.     They 

are  then  tied  down  snugly. 

„,              .                       /        .     1              .  Pig.  112.— The  type  of 

11.  Three  interrupted  stitches  of  adhesion  and  the  position 
number  3  (40-day)  chromic  catgut  are  of  the  kidney  (upper  pole 

J  ,     .  ,  at  the  last  rib)  as  secured 

used  to  bring  the  muscle  edges  to-  by  the  Edebohls'  neph- 
gether  over  the  kidney  to  prevent  rorrhaphy.  (After  Ede- 
hernia. 

12.  The  fascia,  fat  and  skin  are  closed  as  in  any  wound.  The 
wound  is  dressed  with  gauze  and  collodion  and  adhesive  straps. 

13.  The  patient  is  kept  in  bed  for  three  weeks,  but  need  be 
off  her 'back  only  for  the  first  twenty-four  hours. 

Dystopic  kidney  is  the  congenitally  low  kidney,  at,  near 


^ 


26o  PATHOLOGICAL   SEQUELAE    OF    CHILDBIRTH 

or  even  below  the  pelvic  brim.  The  vessels  come  from  the 
internal  iliacs,  and  the  ureter  is  short,  hence  the  reposition  to 
its  normal  position  is  impossible.  Diagnosis  can  be  made 
definitely  by  catheterizing  the  ureters  with  a;-ray  catheters 
and  a;-ray  picture.  The  condition  is  of  no  importance  except 
in  labor,  but  should  be  excluded  before  any  attempt  at  reposi- 
tion of  the  kidney  is  made. 

VII.  FRACTURE  OF  THE  COCCYX 

Fractured  coccyx  is  most  common  in  justominor  pelves, 
especially  where  forceps  have  been  used,  and  in  elderly  primip- 
arse.  The  injury  may  occur  spontaneously.  It  is  most 
commonly  a  rupture  of  the  joint  between  the  first  and  second 
pieces  of  the  coccyx. 

Mechanism. — The  mechanism  of  a  fracture  of  the  coccyx, 
resulting  in  permanent  mobility,  is  first  a  fall,  where  the 
coccyx  is  driven  in  the  pelvic  canal,  rupturing  the  posterior 
longitudinal  ligament,  and  causing  the  coccyx  to  project  much 
further  than  normal  into  the  pelvic  canal.  In  labor,  the  head 
pushes  the  coccyx  in  the  opposite  direction,  causing  a  rupture 
of  the  anterior  longitudinal  ligament,  and  a  separation  of  the 
joint  between  the  first  and  second  pieces. 

Terminations. — (i)  The  coccyx  may  ankylose  inward  (into 
the  pelvic  canal)  when  spontaneous  cure  results,  until  the 
next  labor  breaks  it  again;  (2)  ankylosis  backward,  in  a 
straight  line,  so  that  the  patient  sits  upon  the  tip  of  it,  like 
a  nail;  (3)  permanent  painful  mobility,  coccygodynia — much 
the  commonest.  The  first  requires  no  treatment,  the  others 
require  removal  of  the  bone. 

Causes  of  Coccygeal  Pain. — Pain  is  not  always  due  to 
injury  of  the  bone.  The  causes  of  coccygeal  pain  are:  (i) 
Injury;  (2)  reflex  (from  retroversion  of  the  uterus);  (3)  rheu- 
matic; (4)  neurotic. 

It  should  be  an  invariable  rule  never  to  remove  the  coccyx 
unless  injury  can  be  demonstrated. 

Symptoms  of  Painful  Mobility. — (i)  The  patient  complains 


FRACTURE  OF  THE  COCCYX 


261 


of  pain,  at  the  end  of  the  spine,  on  walking,  sitting  or  par- 
ticularly on  defecation;  (2)  she  has  difficulty  on  arising  from  a 
chair;  (3)  she  sits  on  one  buttock,  and  cannot -remain  long  in 
one  position. 

Diagnosis. — With  the  patient  in  the  Sims'  (left  lateral) 
posture,  one  forefinger,  protected  by  a  fingercot  or  glove,  is 
inserted  in  the  rectum  and  the  coccyx  grasped  between  this 
finger  and  the  thumb  outside.  There  is  always  normal 
anteroposterior  motion  of  about  1.5  cm.  If  the  coccyx  can  be 
moved  laterally;  if  the  movement  causes  pain,  and  if  by  pres- 


PiG.   113. — Testing  the  coccyx  for  fracture  by  separating  the  fragments. 
(After  B.  C.  Hirst.) 

sure  a  step  can  be  made  between  the  upper  and  lower  frag- 
ments, the  bone  is  injured.  X-ray  does  not  show  the  injury. 
Treatment. — At  least  six  months  after  labor  should  be 
allowed,  for  possible  spontaneous  ankylosis.  A  mild  ointment 
(i  per  cent,  or  2  per  cent,  iodin)  may  be  used  externally  over 
the  bone,  chieify  as  a  placebo.  If  spontaneous  cure  is  not 
effected,  or  if  the  coccyx  ankyloses  backward,  its  removal  is  in- 
dicated. The  coccyx  is  exposed  by  an  incision  over  it,  as  far 
from  the  anus  as  possible.  The  bone  is  dissected  loose  from  its 
attachments  with  scissors,  care  being  taken  not  to  wound  the 
rectum,  which  is  close  underneath.     The  dissection  is  carried 


262  PATHOLOGICAL    SEQUELS    OF    CHILDBIRTH 

above  the  lateral  alae  on  the  first  piece  of  the  coccyx,  and  the 
bone  amputated  with  a  Gigli  saw  between  these  alae  and  the 
tubercles  marking  the  last  piece  of  the  sacrum.  It  is  important 
tha,t  all  the  coccyx  be  removed;  amputation  through  the  rup- 
tured joint  will  not  relieve  the  symptoms.  The  median  sacral 
artery  is  tied,  the  deep  wound  drained  with  a  few  strands  of 
silkworm-gut  (horsehair  drain)  and  closed  with  interrupted 
stitches  of  silkworm-gut,  so  that  all  dead  space  is  obliterated. 
Serious  or  even  fatal  infection  may  result  if  the  wound  is  im- 
properly closed.  It  is  dressed  with  gauze  and  collodion,  and 
kept  as  clean  as  possible.  The  stitches 
are  removed  in  two  weeks. 

For  some  weeks  the  patient  will  have 
to  sit  on  an  air  cushion,  as  the  wound  is 
exceedingly  tender .  A  horseshoe-shaped 
cushion  is  best,  and  is  used  with  the 
open    end   at   the   back.     The    wound, 

during    convalescence,    is    exceedingly 
Fig.  114.— The  line  of      ,.„    ^.  ,  ,        '  ,    ,  */ 

amputation    in    coccy-    difficult  to  keep  clean,  and  frequently 

gectomy.    The  last  piece    suppurates.     It    is    not    necessary   nor 

of  the  sacrum  has  tuber-         ,..,.,.  , 

cles  but  no  lateral  als;    advisable,   m   this  casc,  to  remove  the 
the  first   piece  of    the    stitches,  as  the  wound  can  be  flushed 

coccyx    has    lateral    alse       -,  ,  .  , 

but  no  tubercles.    The    through  the  drainage  tract  and  between 
Hne  of  amputation  Hes    the  stitches,  twice  daily,  with  Dakin's 

between  them.  n    •  i  n  •   i       •  1         i         i  i- 

nuid,  which  is  much  the  best  tor 
irrigation.  To  remove  the  stitches  for  infection  retards  heal- 
ing for  many  weeks. 

VIII.  RELAXATION  OF  THE  SACRO-ILIAC  JOINTS 

This  is  a  common  consequence  of  childbirth,  but  may  also 
occur  from  any  sudden  jar  or  strain.  The  condition  is 
described  in  Chapter  XII. 

IX.  RECTOCELE 

Rectocele  is  caused  by  a  bulging  forward  of  the  anterior 
wall  of  the  rectum,  covered  by  the  posterior  vaginal  wall, 
through  a  tear  in  the  fascia  between  the  levator  and  deep 


CYSTOCELE 


263 


transversus  perinei  muscles,  and  the  triangular  ligament.  The 
patient  will  usually  mistake  the  condition  for  prolapse  of 
the  uterus,  and  will  complain  of  difficulty  in  defecation,  due 
to  the  column  of  feces  being  diverted  from  its  normal  path. 

Diagnosis. — With  the 
patient  in  the  dorsal  po- 
sition, the  labia  are  sepa- 
rated, and  she  is  asked  to 
strain.  The  bulging  forward 
of  the  rectocele  is  obvious. 

Treatment. — Proper  re- 
pair of  the  perineal  floor  and 
body,  as  described  under 
lacerations  of  the  birth 
canal,  is  the  proper  treat- 
ment. In  all  cases  where 
the  rectocele  is  marked,  the 
Hegar  shape  of  denudation 
is  better  than  the  Emmet. 

A  common  cause  of  re- 
currence of  a  rectocele,  after 
even  a  properly  performed 
plastic  operation,  is  chronic 
constipation  and  the  conse- 
quent forward  push  of  the 
column  of  fecal  matter,  with        ^^  a      u  1         ^-       c  .u 

_        '  i^iG.   115.— An  old  laceration  of  the 

the  patient's  straining  ef-  perineum  in  both  sulci.  Rectocele. 
forts.       It     is     vital     to     the     Jhe  mouth  of  the  vagina  is  held  open 

to  show  the   appearance  of  the  parts 
success    of    a    plastic    opera-     before  operation:  a,   Apex  of  the  rec- 

tion    that    constipation    be    *°^^^«-    (P'^^°''-^ 

prevented,  and  this  should  be    done  by  laxatives.     Merely 

emptying  the  lower  bowel  by  enema  is  not  sufficient. 

X.    CYSTOCELE 

Cystocele  is  a  bulging  downward  of  the  bladder,  and  anterior 
vaginal  wall. 


264 


PATHOLOGICAL    SEQUELS    OF    CHILDBIRTH 


Causes. — (i)  Laceration  of  the  muscle  of  the  urogenital 
trigonum;  (2)  diastasis  of  the  anterior  vaginal  fascia;  (3) 
elongation  of  the  utero vesical  and  cardinal  Hgaments. 

While  a  cystocele  often  develops  after  spontaneous  delivery, 
the  most  important  predisposing  cause  of  a  cystocele  is  traction 
by  forceps,  particularly  axis-traction  forceps,  before  the  head 
has  passed  through  the  cervix,  and  improper  direction  of  puU 
on  the  forceps  at  any  stage  (outward  instead  of  downward  until 
the  head  is  under  the  pubic  arch) .     The  injury  often  does  not 

appear  until  several  months 
or  even  many  years  after 
labor.  Its  proper  correction 
in  all  cases  is  one  of  the  as 
yet  unsolved  problems  of 
gynecology. 

Cystocele  ma}^  occur  in 
nulliparous  women  or  even 
virgins,  but  except  as  a 
consequence  of  childbirth  it 
is  exceedingly  rare.  It  is 
always  associated  with  some 
degree  of  prolapse,  and  in 
procidentia,  the  greatest  part 
of  the  protruding  mass  is  the 
cystocele. 

Mechanism.  —  Cystocele 
usually  begins  in  the  upper 
part  of  the  anterior  vaginal 
wall,  near  the  cervical  attach- 
ment. As  a  result  of  intra-abdommal  pressure,  in  the  erect 
posture  the  vaginal  wall  is  gradually  dragged  away  from  its 
attachment  to  the  pubic  rami,  and  the  anterior  vaginal  wall 
first  appears  at  the  vulvar  orifice  and  later  bulges  through  it. 
Occasionally  only  the  anterior  third  of  the  vaginal  wall  is  m- 
volved,  and  in  this  case  the  moderate  protrusion  is  called  ure- 
throcele.    This  is  to  be  distinguished  from  the  hypertrophy 


Fig.   116.- 


-Rectocele  and  cystocele. 
(Penrose.) 


CYSTOCELE 


265 


of  the  suburethral  vaginal  mucosa,  often  seen  as  a  result  of 
pregnancy. 

Symptoms. — (i)  The  patient  complains  of  some  protrusion 
from  the  vulva,  which  she  is  likely  to  call  the  uterus;  (2)  vesical 
irritation,  from  decomposition  of  residual  urine,  in  the  pouch 
below  the  urethra. 

Diagnosis.  —  With  the  patient  in  the  dorsal  position,  the 
labia  separated,  she  is  asked  to  strain.  The  protrusion  of  the 
anterior  vaginal  wall  is  very  obvious.  It 
is  not  advisable  to  test  the  position  of 
the;,  bladder  by  the  insertion  through 
the  urethra  of  a  sound.  There  is  great 
danger  of  injury  to  the  vesical  mucosa 
and  consequent  ulcer.  A  suburethral  ab- 
scess, from  Skene's  glands,  looks  not  unlike 
a  cystocele,  but  the  absence  of  bulging  on 
straining,  the  brawny  feel  and  pus  oozing 
from  the  urethra  should  make  the  diagnosis 
easy. 

Treatment. — Palliative  by  the  globe, 
ball-and-stem,  air-cushion  ring,  Menge, 
Schatz,  or  Gehrung  pessaries.  The  pal- 
liative treatment  is  never  curative,  and  is 
simply  a  crutch,  and  is  indicated  in  those 
cases  only  where  operation  is  inadvisable 
or  impossible. 

1.  The  globe  pessary  is  a  hard  rubber  ball,  inserted  in 
the  vagina  and  held  in  place  partly  by  its  size  and  partly  by  a 
protective  napkin  worn  by  the  patient.  It  has  the  advantage 
of  simplicity,  but  is  likely  to  be  forced  out  if  the  patient 
strains. 

2.  The  ball-and-stem  pessary  is  a  hard  rubber  ball  on  a  stem, 
which  in  turn  is  held  in  place  by  an  abdominal  belt  with  peri- 
neal straps.  It  is  efficient,  but  is  a  cumbersom.e  harness  and 
usually  objectionable  to  the  patient. 

3.  The  soft  rubber  air-cushion,  either  singly  or  as  the  Hewitt 


Pig.  iiy.^Globe 
pessary  with  stem. 
(B.  C.  Hirst.) 


266 


PATHOLOGICAL   SEQUELS    OF    CHILDBIRTH 


triple  ring  should  never  be  used.     It  becomes  very  foul  after 
a  short  residence,  and  there  is  considerable  danger  of  sepsis. 
4.  The   Schatz  door-knob  pessary  is  simple  and  efficient. 
It  is  shaped  exactly  like  a  door  knob,  and  is  inserted  with  the 


Pig.   118. — Different  forms  of  the  ring  pessary  for  prolapse  or  cyslocele. 
Unsatisfactory  because  they  usually  turn  sideways  and  drop  out. 

knob  against  the  cervix.  The  shank  of  the  pessary  keeps 
the  knob  transverse  in  the  vagina,  and  hence  the  pessary  does 
not  drop  out.  It  completely  fills  the  vagina,  and  makes  coitus 
impossible. 


Pig.    119. — Schatz's  door-knob  pessary  for  prolapse  of  the  uterus.      Not 
quite  so  efficient  as  the  Menge,  but  based  upon  the  same  principle. 

5.  The  Menge  pessary  is  similar  in  principle  to  the  Schatz, 
except  that  the  bulb  forming  the  shank  of  the  pessary  is  detach- 
able, to  facilitate  removal.  It  is  very  efficient,  but  also  fills 
the  vagina  completely. 

6.  The  Gehrung  pessary  consists  of  two  horseshoe-shaped 


CYSTOCELE 


267 


arches  joined  at  their  heels.  It  is  inserted  so  that  the  heels 
of  the  arch  are  laterally  pressing  against  the  remains  of  the 
pelvic  floor,  and  the  keystone  of  the  arch  up  against  the  bladder. 
It  is  fairly  efi&cient,  as  long  as  it  does  not  change  its  position, 
which  it  is  very  prone  to  do. 


Pig.   120. 


-The   Menge  pessary  for  prolapse, 
inserted. 


Showing  its  position  when 


The  Menge  and  Schatz  pessaries  are  the  best.  They  must  be 
removed  every  six  to  eight  weeks,  the  vagina  inspected  for 
erosion  and  if  none  be  found,  the  pessary  is  cleaned  and  re- 
inserted. Usually  after  some  months  there  has  been  some 
contraction  of  tissue,  so  that  a  smaller  pessary  than  the  one 


268 


PATHOLOGICAL   SEQUELS   OF    CHILDBrRTH 


at  first  used  can  be  inserted.  If  any  erosion  occurs,  the  pessary 
must  be  left  out  for  several  weeks  and  the  patient  takes  a  daily 
douche  of  normal  salt  solution.  After  the  erosion  has  disap- 
peared, the  pessary  can  be  reinserted.  In  the  average  case, 
erosion  will  occur  about  twice  a  year;  more  frequently  the 
older  the  patient. 

These  directions  apply  to  some  degree  to  all  pessaries,  but 
particularly  to  the  Schatz,  Menge  and  Gehrung. 

Operative  Treatment. — A  great  number  of  operations  have 
been  devised,  but  there  is  no  single  operation  applicable  to  all 
cases.  The  age  of  the  patient,  the  degree  of  cystocele,  and 
the  method  of  its  production  must  be  considered. 

I.  The  Stoltz  purse-string  operation  is  applicable  only  to 
small    cystoceles,    and    particularly    to    urethrocele.     It    is 

a 


Fig.  121. — Operations  for  cystocele.  Prom  left  to  right:  i.  Stoltz 
purse  string  operation.  2.  Old  oval  denudation.  3.  Martin  operation. 
4.  B.  C.  Hirst  operation,  a,  Urethra;  b,  cervix;  c,  denuded  area;  d, 
stitch. 

an  archaic  method,  but  fairly  effective.  The  technic  is 
denudation  of  a  circular  space  covering  the  arch  of  the  cysto- 
cele and  a  purse-string  suture  of  number  2  chromic  forty- 
day  gut  is  then  placed  around  this,  taking  care  that  the 
needle  does  not  penetrate  the  bladder. 

2.  The  Martin  operation  is  efficient,  except  in  large  cysto- 
celes.  An  oval  denudation  is  made,  covering  the  area  of  the 
cystocele,  and  wit!  a  running  stitch  of  number  2  chromic  forty- 
day  catgut,  the  denuded  area  is  gradually  obliterated,  with 
several  tiers  of  stitches.  If  this  denudation  is  carried  out  far 
enough  laterally  to  expose  the  retracted  fascia,  the  results  are 
very  satisfactory. 


CYSTOCELE  269 

3.  The  Hirst  (B.  C.)  operation  is  valuable,  also  in  moderate 
cases.  The  cervix  is  caught  and  pulled  down.  A  longitudinal 
incision  is  made  from  the  base  of  the  urethra  to  the  cervico- 
vaginal  attachment,  and  a  transverse  incision  across  the  cer- 
vix, so  the  shape  of  the  incision  is  an  upside  down  T.  The 
anterior  vaginal  mucosa  is  dissected  away  from  the  bladder, 
until  the  lateral  fascia  is  exposed.  The  uterovesical  ligament 
is  cut  and  the  bladder  pushed  up.  The  lateral  fascia  is  then 
brought  together  in  the  middle  line,  using  interrupted  stitches 
of  number  3  chromic  catgut.  The  excess  of  mucosa  is  cut  off 
and  the  vaginal  flaps  closed.  Interrupted  stitches  are  better 
than  continuous,  as  the  latter  causes  too  snug  a  closure  and 
favors  development  of  a  hematoma. 

4.  The  Goffe  operation  is  like  the  preceding  until  the  bladder 
is  dissected  free  and  the  uterovesical  ligament  cut.  Then  a 
retractor  is  placed  under  the  bladder,  the  peritoneaL  pouch 
caught  and  opened,  and  the  bladder  suspended  to  each  uterine 
cornu  and  the  uterine  fundus  with  stitches  of  linen 
thread.  The  peritoneum  is  closed  and  the  vaginal  wound 
repaired. 

5.  The  Watkins-Freund-Wertheim  operation  of  interposi- 
tion of  the  uterus  under  the  bladder,  by  opening  the  anterior 
vaginal  vault  is  the  surest  cure,  but  is  not  usually  done  where 
any  further  childbearing  is  to  be  expected,  unless  the  patient 
is  artificially  sterilized,  by  resection  of  the  Fallopian  tubes  at 
the  uterine  cornu.  It  is  the  only  method  to  be  depended  upon 
in  very  large  cystoceles,  particularly  those  occurring  very  soon 
after  delivery  by  axis-traction  forceps. 

Technic. — (i)  The  bladder  is  dissected  free  and  the  perito- 
neum opened  as  just  described  in  the  Goffe  operation. 

2.  The  uterine  body  is  caught  with  a  tenaculum  and  gently 
pulled  through  the  peritoneal  opening. 

3.  A  stout  curved  needle,  with  number  3  chromic  cat- 
gut catches  the  lateral  fascia  near  the  urethra,  the  fundus 
uteri  between  the  tubes  and  the  lateral  fascia  on  the  other 
side. 


270  PATHOLOGICAL    SEQUELS    OF    CHILDBIRTH 

4.  Four  or  five  similar  stitches  are  inserted,  gradually 
approaching  the  cervix. 

5.  The  bladder  is  pushed  back,  over  the  fundus,  and  the 
stitches  tied  from  above  downward.  This  fixes  the  uterus 
imder  the  bladder,  in  a  position  of  extreme  anteflexion. 

6.  The  excess  mucosa  is  trimmed  off  and  the  vaginal  wound 
closed. 

7.  In  all  interposition  operations  the  convalescence  is 
marred    by    some    degree    of    bladder    irritation    or    actual 


Fig.    122. — The  position  of  the  uterus  and  its  relation  to  the  bladder  after 
the  Watkins-Wertheim  operation  of  interposition.      {After  Crossen.) 

cystitis.  This  can  be  minimized  by  the  routine  use  of 
urotropin,  10  grains  four  times  daily,  for  the  first  three  days 
after  the  operation. 

Permanent  suture  material  is  not  desirable,  as  a  sinus  fre- 
quently results.  These  patients  have  difficulty  in  urination 
for  a  time,  and  have  to  be  catheterized.  They  often  have 
menorrhagia,  for  many  periods  afterward,  but  usually  the 
excess  flow  is  not  great.  In  spite  of  these  drawbacks,  the  opera- 
tion gives  good  results,  when  future  childbearing  is  not  to  be 
expected. 

6.  The  author  has  used,  for  some  years,  with  great  satisfac- 


PROLAPSE    OF   THE   UTERUS  27 1 

tion,  a  variation  of  the  above  technic  by  which  the  uppermost 
uterine  stitch  grasps  the  uterus  at  the  junction  of  the  middle 
and  upper  thirds,  so  that  the  uterus  with  the  lateral  vaginal 
fascia  forms  a  shelf  on  which  the  bladder  rests,  but  is  not 
anteflexed.  Several  patients,  on  whom  this  was  done  have 
passed  through  subsequent  childbirth,  without  dystocia  and 
without  recurrence  of  the  cystocele,  and  he  has,  in  141 
cases,  seen  no  primary  failures. 

7.  In  very  severe  cases,  recurring  after  other  methods,  it 
may  be  necessary  to  open  the  abdomen  and  sew  the  bladder 
fan-shaped  to  the  anterior  abdominal  walls. 

By  one  of  these  methods,  practically  any  case  can  be 
managed. 

XI.  PROLAPSE  OF  THE  UTERUS 

While  the  great  majority  of  cases  result  from  the  inju- 
ries of  childbirth,  there  are  other  causes:  (i)  Sudden  severe 
muscular  effort;  (2)  constant  muscular  shocks  (as  in  a  chronic 
cough) ;  (3)  rupture  of  an  ovarian  cyst  (the  weight  of  the  fluid 
in  the  lower  abdomen  acting  as  a  mechanical  cause). 

Too  early  rising  after  labor,  with  the.  resumption  of  hard 
work,  associated  with  unrepaired  lacerations  is  the  commonest 
cause  of  prolapse;  a  predisposing  factor  is  forceps  delivery 
through  a  partially  dilated  or  partly  effaced  cervix,  axis-traction 
forceps,  or  improper  direction  of  pull  in  any  forceps  operation. 

Degrees  of  prolapse  are  named  from  the  position  of  the 
cervix;  such  as:  Prolapse  with  cervix  on  the  pelvic  floor,  or 
at  the  outlet.  Any  prolapse  in  which  the  cervix  or  rest  of  the 
uterus  is  outside  the  vulvar  orifice  is  called  total  prolapse  or 
procidentia  uteri. 

Mechanism. — (i)  Laceration  of  the  pelvic  floor,  allowing  the 
uterus  to  sag  until  its  ligaments  become  suspensory;  (2) 
retroversion  of  the  uterus,  until  its  axis  coincides  with  that 
of  the  vagina;  (3)  descent  of  the  uterus  by  stretching  of  the 
uterosacral  ligaments  and  the  vaginal  attachments  to  the 
pubic  rami. 


272  PATHOLOGICAL   SEQUELS   OF    CHILDBIRTH 

Symptoms. — (i)  Loss  of  support,  felt  worst  toward  evening, 
when  the  patient  has  been  on  her  feet  all  day;  relieved  by  rest 
in  bed;  (2)  complaint  of  protrusion  through  the  labia  of  the 
cervix  or  other  portion  of  the  uterus  (depending  upon  the 
degree  of  prolapse) .  The  degree  of  prolapse  is  named  from  the 
position  occupied  by  the  cervix,  when  the  patient  is  in  the  erect 


Fig.   123. — The  different  stages  of  prolapse  of  the  uterus. 
(After  Kelly.) 

posture.  A  prolapse  in  which  the  cervix  or  uterine  body 
emerges  from  the  vulva,  is  called  complete,  or  procidentia  uteri. 
Diagnosis  is  easy.  The  cervix,  or  more  of  the  uterus,  is  seen 
to  protrude  between  the  labia.  It  is  important  not  to  make 
an  examination  when  the  patient  has  been  some  time  in  bed  or 
just  after  the  removal  of  a  pessary,  as  the  true  degree  of  pro- 
lapse may  not  be  apparent.  Cystocele  is  always  marked,  and 
usually  forms  the  greater  part  of  the  protruding  mass.     The 


PROLAPSE  OF  THE  UTERUS 


273 


vaginal  mucosa  is  usually  thickened  and  rough,  and  may  be  the 
site  of  extensive  ulceration,  especially  near  the  cervix. 

Treatment. — Palliative  treatment  is  indicated  only  when 
operation  is  inadvisable.  It  is  never  curative  and  while  it 
gives  immense  relief,  patients  must  be  made  to  understand 
that  they  must  be  constantly  under  supervision.  Occasion- 
ally, after  the  menopause,  the  genital  atrophy  will  effect  a 


Pig.    124. — Prolapse  of  the  uterus.     The  cervix  is  pulled  down  by  a  double 
tenaculum  on  the  posterior  lip.      (After  B.  C.  Hirst.) 


spontaneous  cure,  but  this  is  never  to  be  expected.  Usually 
prolapse  gets  worse  after  the  menopause. 

The  palliative  treatment  consists  in  support  by  a  pessary, 
the  same  as  used  in  cystocele.  The  Schatz  and  Menge  are 
much  the  best  in  prolapse,  and  their  use  here  is  exactly  the 
same  as  in  cystocele. 

Operative  Treatment,  i.  Preparatory. — Most  cases  require 
no  preparatory  treatment,  but  often,  as  a  result  of  constant 


274 


PATHOLOGICAL    SEQUELS    OF    CHILDBIRTH 


exposure,  friction  of  the  thighs  clothing  and  irritation  by  urine 
and  perspiration,  the  vaginal  mucosa  is  the  seat  of  extensive 
iilcers.  These  must  be  healed,  before  any  operation  is 
undertaken. 

1.  The  patient  is  kept  off  her  feet. 

2.  The  uterus  is  replaced  and  held  in  place  by  tampons 
with  25  per  cent,  boroglycerid. 

3.  The  ulcers  are  painted 
with  20  grains  to  the  ounce 
nitrate  of  silver  solution, 
three  times  a  week. 

4.  The  patient  takes 
twice  daily  in  the  interval 
between  tampons,  a  vaginal 
douche  of  hot  normal  salt 
solution.  Under  this  treat- 
ment, the  ulcers  disappear 
in  four  to  six  weeks. 

Irreducible  prolapse  is 
the  name  given  when  the 
uterus  has  been  so  long 
prolapsed  that  it  is  con- 
gested, swollen  and  cannot 
easily  be  replaced.  It  can 
be  managed,  however,  by 
(i)  knee-chest  posture;  (2) 

wrapping  the  protruding  mass  in  towels,  wrung  out   of  very 

hot    water;    (3)    pressure   to  reduce  engorgement;  (4)  taxis, 

upward,  like  in  incarcerated  hernia. 

Operation. — The  best  method  is  that  which  does  not  do  too 

much  violence  to  the  normal  anatomy  and  leaves  the  patient 

in  as  normal  a  condition  as  possible. 

The  following  technic  has  given  excellent  results: 

1.  The  patient  is  arranged  as  for  a  plastic  operation,  in 
the  dorsal  position. 

2.  The  cervix  is  caught  with  double  tenacula  and  pulled 
down. 


Pig.  125. — Prolapse  of  the  uterus 
and  rectum.  {A  uthor's  case,  Phila- 
delphia General  Hospital.) 


PROLAPSE    or    THE    UTERUS 


275 


3.  The  cervix  is  amputated,  by  the  Hegar  technic. 

4.  The  cervical  canal  is  dilated  and  the  uterine  cavity 
curetted.  This  is  done  after  amputation,  because  the  cervix 
is  usually  too  long  for  effective  dilatation. 


Fig.   126. — Prolapse  of  uterus  and  bladder      Notice  that  the  bulk  of  the 
protruding  mass  is  cystocele. 

5.  A  Watkins-Freund  operation  is  done  for  the  cystocele. 

6.  An  extensive  Hegar  perineorrhaphy  is  done. 


Pig.   127. — The  Goddard  pessary  for  prolapse,  cheap  and  efficient,   but 
requires  a  bandage  around  the  waist  for  support. 

No  abdominal  operation  is  necessary  for  prolapse.  The 
cystocele  operation  eliminates  retroversion,  and  the  plastic 
work,  properly  done,  is  ample  for  support. 

A  common  mistake  is  to  perform  vaginal  or  abdominal 


276  PATHOLOGICAL    SEQUELS    OF    CHILDBIRTH 

hysterectomy.  This  should  never  be  done  unless  there  is 
uterine  carcinoma  and  should  then  be  followed  by  extensive 
plastic  work  on  the  anterior  and  posterior  vaginal  walls,  to 
prevent  inversion  of  the  vagina,  which  will  surely  follow  if 
this  be  neglected.  Neither  vaginal  hysterectomy  nor  ventro- 
fixation of  the  uterus  will  alone  cure  prolapse  of  the  uterus, 
unless  combined  with  extensive  vaginal  repair. 

Most  operations  for  prolapse  are  done  at  an  age  when  further 


Fig.  1 2 8. ^Complete  inversion  of  the  vagina,  following  vaginal 
hysterectomy  for  prolapse  of  the  uterus.  {Author's  case,  St.  Agnes 
Hospital.) 

childbearing  is  unlikely.  In  young  women,  however,  lacera- 
tion is  likely  to  recur  at  any  future  delivery,  but  proper 
repair  at  that  time  will  usually  prevent  any  recurrence  of  the 
prolapse.  In  most  cases  of  prolapse  in  women  in  the  child- 
bearing  age,  it  is  desirable  that  no  further  pregnancy  occur. 


INCONTINENCE    OF   URINE  277 

This  can  be  managed  by  resection  of  the  tubes  at  the  uterine 
cornua,  during  the  cystocele  operation,  and  hysterectomy 
is  an  unnecessarily  radical  method. 

XII.  INCONTINENCE  OF  URINE 

Incontinence  of  urine  is  due  to  fi)  Paralysis  of  the  vesical 
sphincter;  (2)  overflow  from  retention;  (3)  laceration  of  the 
urogenital  muscle  (compressor  urethrae);  (4)  fistula;  (5)  pull 
upon  the  vesical  neck  by  a  retroverted  uterus. 

The  sjmiptoms  are  obvious.  There  is  a  leakage  of  urine, 
either  constantly  or  upon  any  exertion. 

The  diagnosis  of  the  cause  may  be  difficult.  The  in- 
continence of  the  overflow  is  easily  overcome  by  the  catheter 
(soft  rubber  or  silk  and  not  glass).  That  due  to  fistula  can 
be  managed  only  by  the  closure  of  the  fistula.  Incontinence 
only  upon  sudden  muscular  effort  is  almost  always  due  to 
laceration  of  the  muscle  of  the  urogenital  trigonum,  the  repair 
of  which  will  be  found  described  in  the  chapter  on  the  injuries 
of  the  birth  canal.  Retroversion  is  diagnosed  by  manual 
examination.  If  none  of  these  causes  are  responsible,  the 
cause  is  paralysis  of  the  vesical  sphincter.  Moderate 
cases  tend  to  recover  spontaneously.  Cases  of  long  standing 
are  exceedingly  difl&cult  to  treat.  Large  doses  of  strychnin 
(grain  }y^Q  four  times  a  day)  over  a  long  period  and  the  slow 
interrupted  faradic  current,  one  pole  in  the  urethra  and  the 
other  on  the  abdomen,  applied  for  45  minutes  every  day 
will  often  hasten  a  cure.  If  a  reasonable  trial  fails,  injections 
of  paraffin  (melting  point  iio°F.)  are  often  successful.  The 
injection  is  made  in  the  tissues  between  the  anterior  vaginal 
wall  and  the  vesical  neck,  and  is  dumb-bell  shaped,  with  the 
transverse  bar  across  the  vesical  neck.  The  effect  is  that  due 
to  slight  pressure.  The  paraffin  can  be  removed  at  any 
time,  by  incision  and  enucleation,  and  this  should  be  done  in  the 
event  of  future  pregnancy,  as  the  pressure  of  the  child's  head 
on  the  mass  of  paraffin  might  be  disastrous  to  the  bladder. 
In    otherwise    intractable    cases,    surgical    methods    are    (i) 


278 


PATHOLOGICAL   SEQUELS    OF    CHILDBIRTH 


shortening  the  vesical  sphincter;  (2)  extensive  cystocele  opera- 
tion; (3)  interposition  operation.  They  should  be  tried  in 
this  order. 

XIII.    GENITAL  FISTULA 

The  causes  of  genital  fistulae  are:  (i)  Sloughing  from  con- 
tinued pressure  in  obstructed  labor — now  becoming  rare,  due  to 
better  management;  (2)  lacerations  from  violent  delivery  or 
slipping  forceps;  (3)  abscess;  (4)  tuberculosis;  (5)  syphilis;  (6) 
cancer —  in  its  later  stages. 

Kinds. — A  long  list  of  fistulae  may  be  made  by  connecting 
in  every  possible  way  the  bladder,  vagina,  rectum,   ureter 


Pig.  129. — Fistulas  of  the  genital  organs:  a,  Vesico-uterine  fistula; 
b,  vesicocervical  fistula;  c,  vesicovaginal  fistula;  d.  urethrovaginal  fistula; 
e,  rectovaginal  fistula;  /,  perineovaginal  fistula.      (Beigel.) 

intestine,  uterus  and  urethra.  By  far  the  commonest  are,  in 
order:  (i)  Vesicovaginal;  (2)  rectovaginal;  (3)  uretero vaginal; 
(4)  vesico-cervico-vaginal. 

Diagnosis  of  Vesicovaginal  Fistula. — The  patient  complains 
of  constant  dribbling  of  urine;  usually  excoriation  of  the  labia 
and  thighs,  and,  if  the  fistula  is  of  long  standing,  cicatricial 


GENITAL   FISTULA  279 

contractions  of  the  vagina.  In  very  small  fistulas  there  may 
be  leakage  only  in  certain  positions,  or  when  the  bladder  is 
full.  Almost  always  there  is  a  complicating  cystitis.  The 
demonstration  of  a  fistula  may  not  be  easy.  Large  ones  can 
usually  be  seen  at  once,  but  a  small  fistula  may  be  so  hidden 
by  a  fold  of  the  vaginal  mucosa,  that  it  is  difficult  or  impossible 
to  see  it.  If  the  fistula  cannot  be  seen  (usually  near  the  cervix 
and  toward  one  vaginal  vault)  when  the  vagina  is  expanded 
by  a  bivalve  speculum,  other  means  of  diagnosis  must  be 
used,  (i)  Searching  with  a  probe — a  rather  clumsy  method; 
(2)  cystoscopy,  as  the  bladder  end  of  the  fistula  is  usually 
easier  to  see,  and  a  probe  or  ureteral  catheter  can  then  be 
passed  through  it;  (3)  injection  into  the  bladder  of  colored 
fluid,  when  its  point  of  leakage  can  be  seen.  The  best  fluid 
is  sterile  milk,  and  four  ounces  is  enough.  If  the  fistula  is 
so  small  that  leakage  only  occurs  in  the  erect  posture,  the 
bladder  may  be  injected  with  2  per  cent,  methylene  blue 
solution,  small  pledgets  of  cotton  placed  in  the  vaginal  vaults 
and  the  patient  allowed  to  walk  about  for  a  few  minutes. 
The  pledget  of  cotton  marking  the  site  of  the  fistula  will  be 
stained  blue.  By  these  injections,  incontinence  due  to 
paralysis  of  the  vesical  sphincter  may  be  excluded. 

Treatment  of  Vesicovaginal  Fistula! — No  attempt  should  be 
made  to  repair  the  fistula  until  puerperal  involution  is  complete. 
Two  or  three  months  after  labor  is  the  most  favorable  time. 
Very  small  fistulse  may  sometimes  be  made  to  heal  by  cauteri- 
zation with  nitric  acid  or  a  red-hot  probe  or  electric  needle. 
This  method  is  not  usually  safe,  as  it  may  cause  the  fistula  to 
enlarge  instead  of  heal.  Usually,  the  steps  of  repair  are: 
(i)  For  at  least  a  week  before  operation,  the  bladder  should 
be  flushed  with  boric  acid  solution,  twice  daily. 

2.  For  the  operation,  the  patient  is  anesthetized,  placed  in 
the  dorsal  (or  Sims)  position,  and  prepared  locally  as  for  a 
plastic. 

3.  The  fistula  is  located,  and  denudation  is  made  around  it, 
down  to  but  not  through  the  vesical  mucosa. 


28o 


PATHOLOGICAL   SEQUELS    OF   CHILDBIRTH 


4.  The  edge  of  the  fistula  is  spht,  so  as  to  separate  it  from  the 
anterior  vaginal  wall. 

5.  The  bladder  wall  is  closed  with  interrupted  number  i 
chromic  catgut  or  linen  thread  stitches. 

6.  The  vaginal  mucosa  and  fascia  is  closed  over  the  bladder 
wall  by  interrupted  stitches  of  linen  thread.  The  denudation 
should  be  so  planned  that  as  little  tension  on  the  stitches 
as  possible  will  result. 


Fig.  130.  Fig.  131. 

Fig.    130. — The  simplest  form  of  operation  for  vesicovaginal  fistula. 
Fig.    131. — The  flap-splitting  operation  for  vesicovaginal  fistula. 

7.  The  bladder  is  kept  from  overflowing  by  a  permanent 
mushroom  catheter,  or  better  by  catheterization  every  four 
hours,  as  the  permanent  catheter  is  likely  to  cause  trouble- 
some cystitis. 

The  linen  stitches  are  removed  in  two  weeks.  Com- 
plete success  is  not  common  at  the  first  trial,  and  re-operations 
are  frequent.  If  the  vagina  is  the  seat  of  cicatricial  contrac- 
tion,  the  bands  must  be  cut,   the  vagina  dilated  with  glass 


GENITAL   FISTULA  261 

plugs  and  the  normal  elasticity  restored  as  far  as  possible,  be- 
fore any  repair  is  attempted.  Syphilitic,  tubercular  and 
cancerous  fistulae  should  not  be  touched  surgically,  as  they  are 
impossible  to  repair.  Very  large  fistulae,  so  large  that  no  flaps 
can  be  made  by  dissection  and  undermining  of  the  edges  may 
be  treated  in  one  of  two  ways,  (i)  Opening  the  anterior 
vaginal  vault,  anteverting  the  uterus,  and  sewing  the  uterine 
body,  as  a  plug,  in  the  opening  in  the  bladder;  (2)  complete 
closure  of  the  vagina^ — colpocleisis — so  that  the  bladder  and 
vagina  form  one  cavity.  This  is  so  often  followed  by  ascend- 
ing infection  of  the  ureters,  pyelonephrosis  and  fatal  sepsis, 
that  its  use  seems  unjustifiable. 

Diagnosis  of  Rectovaginal  Fistulae. — The  patient  complains 
of  passing  fecal  matter  and  gas  through  the  vagina.  The  same 
symptoms  seem  to  occur  in  tear  of  the  sphincter,  and  the 
patient  is  unable  to  distinguish  between  them.  The  fistula 
is  usually  easy  to  see,  and  is  most  often  just  inside  the  vagina  or 
on  the  perineum.  Milk  may  be  injected  and  its  point  of  exit 
noted. 

Treatment  of  Rectovaginal  Fistulae.^ — Repair  is  much  easier 
and  more  certain  of  success  than  in  vesical  fistula.  An  oval 
denudation  is  made  around  the  fistula  down  to  but  not  includ- 
ing the  rectal  mucosa.  The  edge  of  the  fistula  is  split,  to 
separate  the  rectal  wall.  The  opening  in  the  rectum  in  closed 
with  number  i  chromic  catgut,  interrupted  stitches,  and  the 
vaginal  wall  closed  over  it.  The  bowels  are  kept  loose  from 
the  start,  two  movements  a  day  being  required.  Before  any 
attempt  is  made  to  close  an  apparent  rectovaginal  fistula, 
anus  vestibularis  must  be  excluded.  In  these  cases  the  anus 
opens  just  inside  the  vaginal  orifice,  and  has  all  the  appearance 
of  a  fistula. 

A  little  care  in  diagnosis  will  prevent  this  mistake.  Here 
also  syphilitic,  tubercular  and  cancerous  fistulae  cannot  be 
repaired. 

Diagnosis  of  Ureterovaginal  Fistulae.^ — Constant  dribbling  of 
urine,  irrespective  of  the  patient's  position,  but  in  amounts 


282  PATHOLOGICAL    SEQUELS    OF    CHILDBIRTH 

smaller  than  would  be  expected  from  a  vesicovaginal  fistula. 
No  opening  from  the  bladder  can  be  found,  but  the  fistula,  or 
at  least  the  source  of  the  urine,  can  usually  be  seen  in  one 
vaginal  vault.  These  fistulae  are  most  common  after  high 
forceps  deliveries,  or  in  rapid  delivery  of  a  breech  or  in  version. 
Such  a  history  may  help  in  directing  attention  to  the  site  of  the 
fistula.  If  the  fistula  cannot  be  seen,  a  hypodermic  injection 
of  indigo-carmine  (2  mils)  is  given.  Then  by  placing  cotton 
pledgets  near  the  supposed  site,  the  blue  stain  on  the  cotton 
will  serve  to  locate  it. 

Treatment  of  Ureterovaginal  Fistulae.^ — Either  implantation 
of  the  ureter  into  the  bladder  by  the  vaginal  route — colpo- 
ureterocystostomy,  or  by  the  abdominal  route — laparo-ure- 
terocystostomy.  Implantation  of  the  ureter  in  the  bowel  is 
likely  to  cause  ascending  infection  and  pyelitis  and  is  not 
desirable  if  it  can  be  avoided. 

Vesicocervicovaginal  fistula,  from  violence  in  forceps  deliv- 
eries or  too  rapid  extraction  of  the  child  after  version  or  in  a 
breech  presentation,  is  one  of  the  most  difficult  of  fistulse  to 
treat.  The  urine  can  be  seen  emerging  from  the  cervix.  The 
only  way  to  close  the  opening  is  to  dissect  the  anterior  vaginal 
wall  from  the  bladder,  free  the  bladder  by  cutting  the  utero- 
vesical  ligaments,  and  closing  the  fistula  in  the  bladder,  which 
is  thus  exposed,  by  interrupted  sutures  of  linen  thread. 
It  is,  fortunately,  rare. 

It  is  difficult  to  lay  down  any  set  rules  for  operation  for  a 
condition  in  which  each  case  is  a  separate  problem.  The 
method  of  closing  genital  fistulae  must  be  adapted  to  the 
needs  of  the  individual^  case.  The  foregoing  is  merely  an 
outline  of  typical  cases. 


CHAPTER  XIV 

DISEASES  OF  THE  URINARY  TRACT  INCLUDING 
CYSTOSCOPY 

General  Anatomy. — The  kidney  is  essentially  the  same,  in 
its  anatomical  relations,  in  both  sexes. 

The  ureter  in  the  female  is  wider  than  in  the  male;  it  runs 
retroperitoneally  to  the  pelvic  brim,  crosses  the  common 
iliac  just  before  the  internal  iliac  branches  off;  dives  into  the 
pelvis  and  passes  through  the  base  of  the  broad  ligament,  near 
the  cervix,  and  thence  into  the  base  of  the  bladder,  to  empty  into 
the  trigone.  The  uterine  arteries  lie  in  close  relationship 
with  the  ureter,  crossing  in  front  at  the  level  of  the  internal 
OS.  The  left  ureter  lies  much  closer  to  the  cervix  than  the 
right;  and  both  ureters  lie  much  closer  than  normal  to  the 
cervix  when  the  uterus  is  prolapsed  or  pulled  down. 

The  bladder  is  broader  than  in  the  male,  its  normal  capacity 
is  less,  and  its  waits  thinner.  It  is  much  more  dilatable  than  the 
male,  and  lies  deeper  in  the  pelvis.  The  fundus  and  upper 
portion  of  the  anterior  wall  are  covered  by  peritoneum,  the 
posterior  wall  is  not. 

The  trigone  is  a  triangular  space  formed  by  lines  drawn 
between  the  ureteral  orifices  and  the  urethra.  Between  the 
ureters  runs  a  slightly  raised  band  in  the  bladder  wall,  called 
the  interureteric  fold,  which  is  of  great  value  in  locating  the 
ureteral  orifices  in  cystoscopy. 

The  urethra  is  short,  of  large  caliber,  very  dilatable  and  is 
lined  with  pavement  epithelium  in  its  lower,  cylindrical  in  its 
upper  portion.     In  the  floor  lie  Skene's  glands. 

The  blood-supply  of  the  bladder  and  urethra  comes  from  the 
internal  pudic,  inferior  vesical  and  in  part  from  the  uterine 
arteries. 

283 


284 


DISEASES    OF   THE   URINARY   TRACT 


The  veins  empty  into  the  vesicovaginal  plexus. 

The  nerves  are  from  the  pudic. 

The  lymphatics  empty  into  the  deep  hypogastric  and  ingui- 
nal glands. 

Technic  of  examination  of  the  female  urinary  tract,  (i) 
Catheterization  is  often  necessary  to  collect  urine  uncontami- 
nated  by  admixture  of  vaginal  secretions.  There  is  great 
danger  of  cystitis  unless  it  is  carefully  done.  A  satisfactory 
technic  is  as  follows: 

1.  Catheters  must  be  thoroughly  cleaned  after  using  and 
boiled  before  being  put  away. 

2.  Catheters  must  be  boiled  for  ten  minutes  just  before  use. 


Pig. 


132. — The  trigone  of  the  bladder  with  the  ureteral  orifices  and  the 
interureteric  fold. 


3.  Use  soft  rubber  catheters,  and  not  metal  or  glass  ones. 

4.  Get  ready  i  small  basin  lysol  solution  (2  drams  to  i  pint), 
I  small  basin  sterile  water;  sterile  cotton;  sterile  gloves. 
At  night  have  candle  or  flashlight.  Use  catheter  from  basin 
and  water  in  which  it  has  been  boiled,  and  do  not  handle 
except  with  gloves. 

5.  Have  patient  arranged  on  her  back,  knees  drawn  up  and 
separated.  Use  two  fingers  of  gloved  hand  to  separate  labia 
and  expose  urethral  orifice.  With  other  gloved  hand,  wipe  off 
urethral  orifice  with  cotton  and  lysol  solution,  followed  by 

.  sterile  water. 

6.  Pick  up  catheter,  lubricate  end  with  sterile  albolene,  and 
insert  gently. 


CYSTOSCOPY  285 

7.  When  bladder  is  emptied,  withdraw  catheter,  and  wipe  off 
urethral  orifice  again  with  cotton  and  lysol  solution,  followed 
by  sterile  water. 

8.  Always  have  light  enough  to  see,  and  never  trust  to  feeling 
for  the  urethra. 

9.  Cleanse  catheter  after  using  and  always  boil  before  putting 
away. 

10.  Failure  to  observe  these  precautions  may  result  in  serious 
disability  to  a  patient.  There  is  no  excuse  for  a  patient's 
developing  inflammation  of  the  bladder  after  the  use  of  the 
catheter. 

CYSTOSCOPY 

Cystoscopy  is  done  by  two  methods:  (i)  Water  distention  of 
the  bladder;  (2)  air  distention. 

The  method  of  air  distention  is  clumsy  and  inconvenient. 
It  requires  an  exaggerated  Trendelenburg  or  the  knee-chest 
posture,  and  is  of  use  only  when  there  is  so  much  pus  in  the 
bladder  that  a  clear  fluid  for  vision  is  not  obtainable.  The 
instrument  used  is  the  Kelly  open  channel  cystoscope,  requir- 
ing reflected  light  from  a  head  light  or  mirror,  and  the  view 
obtained  is  limited  and  unsatisfactory. 

Water  distention  is  much  more  desirable.  It  does  not 
require  anesthesia,  can  be  done  as  a  routine  ofiice  procedure, 
and  rarely  gives  the  patient  more  than  passing  discomfort.  A 
very  satisfactory  instrument  is  the  Brown-Buerger  special,  with 
a  wide  visual  field.  With  this  cystoscope  it  is  just  possible 
to  see  both  ureteral  orifices  in  the  same  field.  Directions 
for  its  use  are  as  follows: 

1.  Patient  in  lithotomy  position,  no  ether. 

2.  Cleanse  urethral  orifice,  and  if  very  small,  use  small 
urethral  sound  (22). 

3.  Have  cystoscope,  cord  and  catheters  sterilized  by  forma- 
lin vapor.  If  wiped  off  with  alcohol,  never  get  it  or  any  other 
fluid  on  the  eyepiece. 

4.  Easiest  to  use  examining  lens  first  to  locate  ureters,  and 


286 


DISEASES    OF    THE   URINARY   TRACT 


then  change  to  catheterizing  lens.     This  only  in  the  older 
models  with  limited  field  of  vision. 

5.  Lubricate  light  of  scope  only,  never  get  anything  on  lens, 
and  use  only  glycerin  or  water  soluble  lubricant. 

6.  Insert  cystoscope,  turn 
upside  down  (except  in  direct 
vision  scopes),  attach  irrigating 
tube,  and  light  cord. 

7.  Allow  water  to  run  in 
bladder,  until  patient  feels  de- 
sire to  urinate,  then  cut  off 
and  turn  light  on  slowly.  Too 
little  water  in  bladder  is  the 
commonest  cause  of  trouble. 

8.  Always  work  with  as  little 
light  turned  on  as  possible. 
Lights  are  easily  burned  out 
and  are  expensive. 
'  9.  If  fluid  is  cloudy,  let  water 
run  in  and  out  until  clear. 

10.  Look  for  ureters  by 
turning  cystoscope  at  angle  of 
45  degrees  to  perpendicular  on 
each  side  of  bladder.  If  a  doubt- 
ful spot  is  seen  and  you  cannot 
be  sure  whether  it  is  the  ureter, 
watch  it  for  a  few  seconds.  If 
it  is  a  ureter,  it  will  spout  urine. 
Where  the  ureteral  orifices  are 
difi&cult  to  find,  it  is  a  good 
plan  to  inject  into  the  patient's 
thigh  one  mil  of  indigo-carmine. 
After  about  twelve  minutes  both  kidneys  will  begin  to  ex- 
crete the  color,  and  the  spurts  of  blue  urine  from  the 
ureters  makes  their  detection  easy. 

II.   When   finished   with   examining   lens,    turn   light   off, 


Pig.  133. — Sterilizing  plant  for 
cystoscopes  and  catheters.  Loose 
formaldehyd  powder  in  bottom  of 
jar.      Efficient  and  inexpensive. 


CYSTOSCOPY  287 

remove  cystoscope,  change  to  catheterizing  lens,  insert  cathe- 
ters and  proceed  as  before  to  insert  cystoscope  and  find  the 
ureters.     Only  in  instruments  of  limited  field. 

12.  To  catheterize  ureter,  when  located,  focus  it  at  about 
5  o'clock  (right)  or  7  o'clock  (left)  using  the  field  as  a  clock 
face.  Push  catheter  down  till  visible  past  lens.  Guide  it  in 
proper  direction  with  the  hinged  flap  worked  from  the  handle 
of  scope  and  push  in  mouth  of  ureter.  When  in,  put  flap  down 
flat  again  and  then  push  catheter  up  to  pelvis  of  kidney. 

13.  To  push  catheter  in,  grasp  it  with  fingers  as  near  where 
it  enters  the  cystoscope  channel  as  possible,  and  push  m  by 
very  short  steps.     Otherwise  it  will  bend. 

14.  Never  catheterize  a  healthy  ureter  from  an  infected 
bladder. 

15.  To  wash  out  pelvis  of  kidney  use  a  Luer  glass  or  Ricord 
syringe  and  boric  acid  solution  and  then  hegonon  i  per  cent,  or 
silvol  5  per  cent.  The  pelvis  of  the  kidney  should  hold  10  to 
15  c.c.  but  be  guided  by  patient's  complaint  of  pain,  and 
never  persist  after  pain  starts,  and  never  force  the  fluid 
through  the  catheter. 

16.  To  remove  cystoscope  turn  off  light,  disconnect  water 
tube,  be  sure  guiding  Hap  is  Hat  down  and  remove. 

17.  To  leave  catheters  in,  push  up  as  far  as  possible,  allow- 
ing them  to  curl  up  in  bladder.  Leave  only  ^^^  inch  of  catheter 
beyond  eyepiece  of  cystoscope.  Then  remove  cystoscope  as  in 
number  16.  When  catheters  appear  at  urethral  orifice,  hold 
them  and  pull  cystoscope  away  from  them.  Fix  them  to  thighs 
with  adhesive  tape,  let  drain  into  bottles  and  be  sure  before  re- 
moving the  cystoscope  that  you  know  which  is  right  and  which 
left. 

18.  After  using,  dry  cystoscope  with  gauze,  dry  catheters  by 
wiping  off  and  keep  them  with  stylets  in  them.  The  stylets 
should  be  German  silver  and  not  steel  wire,  or  the  latter  rusts 
badly.  Never  get  any  moisture  in  the  eyepiece  of  the  scope. 
This  end  is  not  watertight. 

19.  After  any  case  of  ureteral  catheterization,  there  is  liable 


286  DISEASES    OF    THE    URINARY    TRACT 

to  be  severe  pain,  of  short  duration,  from  the  passage  of  a 
blood-clot  down  the  ureter.  The  pain  simulates  stone,  is 
short  lived,  but  may  require  morphin  hypodermically  to 
relieve  it. 

20.  Injections  into  ureter,  of  antiseptic  solution,  are  most 
useful  in  pyelitis.  The  most  satisfactory  are  silvol,  5-10  per 
cent.,  arg}Tol  25  per  cent.,  protargol  2  per  cent.,  hegonon  i 
per  cent,  and  boric  acid  solution  gr.  10  to  oz.  i.  All  in- 
jections are  made  slowly  and  discontinued  as  soon  as  the 
patient  complains  of  discomfort  in  the  back. 

USES  OF  URETERAL  CATHETER 

\^i)  To  collect  urine  from  the  kidneys  separately;  (2)  diagno- 
sis of  stricture;  (3)  diagnosis  of  stone;  (4)  irrigate  pelvis  of 
kidney;  (5)  .-v-ray  picture;  (6)  to  locate  the  ureter,  in  opera- 
tion for  cancer. 

SEGREGATION  OF  URINE 

In  cases  where  it  is  impossible  or  inadvisable  to  catheterize 
the  ureters,  urine  may  be  collected  from  each  side  of  the 
bladder  separately  by  segregation.  The  Harris  instrument 
is  a  double  bar  inserted  in  the  bladder,  separated,  and  the 
vaginal  and  bladder  walls  pushed  up  between  the  ends,  by  a 
third  bar  in  the  vagina,  so  as  to  make  a  watershed.  The  urine 
is  then  removed  by  suction  with  a  s}Tinge.  The  Cathelin  or 
Luys  instruments  use  a  water-tight  rubber  diaphragm  for  the 
same  purpose.  Segregation  is  not  as  good  as  ureteral  catheteri- 
zation and  should  not  be  used  when  the  latter  is  practicable. 

PYELOGRAPHY 

Pyelography,  or  the  injection  into  the  pelvis  of  the  kidney 
of  a  solution  opaque  to  the  a;-ray,  and  then  taking  an  .x--ray 
picture,  is  of  great  value  in  diagnosis  of  position  and  hydrone- 
phrosis, but  is  not  without  danger,  as  the  solution  wiU  some- 
times penetrate  into  the  renal  parenchyma  or  cause  necrosis 
and  suppuration.  The  best  solutions  are:(i)  thorium  nitrate 
5  per  cent.;  (2)  collargol  10  per  cent.;  (3)  argentide  emulsion. 


PYELITIS  289 

The  amount  used  varies  from  5  to  20  c.c,  depending  upon  the 
capacity  of  the  kidney  pelvis,  and  no  force  must  be  used  in  the 
injections.  When  the  pelvis  is  full,  the  patient  feels  some 
discomfort  in  her  back,  the  injection  is  stopped  and  the  x-ray 
taken  at  once. 

DISEASES  OF  THE  URINARY  TRACT 
I.  Diseases  of  the  Kidney 

PYELITIS 

Pyelitis  is  a  bacterial  infection  of  the  mucosa  of  the  pelvis 
of  the  kidney.  There  are  two  avenues  of  infection:  (i) 
hematogenous,  through  the  circulation;  (2)  ascending  infec- 
tion from  the  bladder,  along  the  ureter.  The  first  is  much  the 
commonest. 

Bacteria. — (i)  Bacillus  aerogenes  mycosum  (of  the  colon 
bacillus  group);  (2)  colon  bacillus;  (3)  pneumococcus;  (4) 
staphylococcus;  (5)  streptococcus;  (6)  gonococcus. 

In  chronic  cases  the  colon  bacillus  or  Bacillus  aerogenes 
mycosurn  are  present  in  pure  culture;  in  acute  cases  staphy- 
lococci, pneumococci  and  streptococci  are  commonly  found. 

Causes. — Predisposing  causes  are  the  tendency  to  hydro- 
ureter  and  hydronephrosis  due  to  a  movable  kidney  or  direct 
pressure  on  the  ureter  against  the  pelvic  brim. 

Actual  Causes. — (i)  Widespread  sepsis,  postoperative;  (2) 
stone;  (3)  puerperal  infections;  (4)  cystitis  and  retention  of 
urine.     In  many  cases  no  exciting  cause  can  be  demonstrated. 

Symptoms. — Acute  Cases:  (i)  Chills  and  high  fever;  (2) 
leukocytosis;  18,000-24,000;  (3)  pain  in  loin,  referred  down 
ureter;  (4)  pyuria. 

Chronic  form  persists  after  an  acute  attack,  but  more  com- 
monly is  subacute  or  chronic  from  the  beginning. 

(i)  Pyuria;  (2)  sensitiveness  to  pressure  in  kidney  region. 
(3)  pain  referred  intermittently  along  ureter;  (4)  moderate 
leukocytosis;  (5)  irritability  of  the  bladder.  Acute  pyelitis 
is  a  dangerous  and  sometimes  a  fatal  infection;  chronic  pyelitis 
may  persist  for  years  with  very  moderate  symptoms. 
19 


290  DISEASES    OF   THE   URINARY    TRACT 

Site. — It  is  most  commonly  unilateral,  and  on  the  right 
side.  It  may  affect  either  side,  however,  and  is  occasionally 
bilateral. 

Urine  Examination. — The  amount  of  albumin  in  the  urine 
is  at  first  in  direct  ratio  to  the  amount  of  pus  present;  a  greatly 
increased  amount  of  albumin  shows  pyelonephritis  with  in- 
volvement of  the  parenchyma.  Casts  are  not  present  in 
simple  pyelitis. 

Functional  tests  for  excretion  of  urine,  in  simple  pyelitis, 
show  little  difference  in  the  two  sides.  Where  the  parenchNona 
of  the  kidney  is  invaded,  however,  that  side  always  shows 
retarded  function. 

{i)  Indigo-carmine. — If  i  mil  of  indigo-carmine  is  injected 
in  the  thigh,  blue  urine  should  be  seen,  through  the  cystoscope, 
to  emerge  from  the  ureters  in  about  twelve  and  a  half  minutes. 
Delay  usually  indicates  improper  function,  though  exceptions 
are  numerous. 

Phenol sulphonphthalein. — Two  to  4  mils  of  phenolsulphon- 
phthalein  are  injected  deep  in  the  patient's  thigh.  She  is 
catheterized  immediately  before  the  injection;  again  in  one 
hour  and  ten  minutes  and  again  in  one  hour.  The  last  two 
specimens  are  saved.  Their  color  is  compared  with  that  in 
the  colorimeter  vials.  About  60  per  cent,  is  the  normal  excre- 
tion in  two  hours.  Less  indicates  improper  function,  although 
wide  variations  are  seen. 

Diagnosis  is  easy.  Cystoscopy  will  show  the  mouth  of  the 
aflfected  ureter  to  be  eroded,  edematous,  and  cloudy  urine  can 
be  seen  to  spout  from  it. 

Causes  of  right-sided  pain  in  women  are:  (i)  Cholecystitis  or 
gall-stones;  (2)  fecal  impaction  in  hepatic  flexure  of  colon; 
(3)  floating  kidney  with  hydronephrosis;  (4)  kidney  stone; 
(s)  ureteral  stone;  (6)  pyelitis;  (7)  appendicitis;  (8)  salpingi- 
tis; (9)  extra-uterine  pregnancy;  (10)  ovarian  cyst  tmsted 
on  pedicle;  (11)  varicose  veins  in  broad  ligament. 

Differential  Diagnosis. — Pyelitis  is  commonly  mistaken  for 
chronic  appendicitis,  but  urine  examination  and  cystoscopy 


PYELITIS  291 

should  clear  up  the  diagnosis  at  once.  It  is  safer  never  to 
operate  for  chronic  appendicitis  in  women,  until  pyelitis  has 
been  excluded. 

Treatment.- — Palliative:  (i)  Rest  in  bed,  on  side  opposite 
the  affected  one;  (2)  ice  bag  to  affected  loin;  (3)  large 
amounts  of  water,  twelve  to  fifteen  glasses  a  day;  (4)  milk 
diet;  (5)  urinary  antiseptics  (salol,  urotropin,  helmitol  gr.  10 
every  four  hours;  (6)  bladder  irrigations,  to  help  ureteral 
peristalsis  and  aid  drainage. 

This  usually  causes  rapid  improvement  in  acute  cases. 

Radical. — Cystoscopy;  catheterization  of  affected  ureter, 
washing  out  of  pelvis  of  kidney  with  boric  acid  solution, 
followed  by  10  to  15  c.c.  of  5  per  cent,  silvol  solution,  or  i  per 
cent,  hegonon,  or  25  per  cent,  argyrol.  This,  possibly  repeated, 
will  cure  most  cases.  It  can  be  done  at  once  in  chronic  cases., 
but  in  acute  ones  is  not  advisable,  due  to  the  danger  of 
pyelonephrosis. 

Vaccine  Treatment. — In  chronic  cases,  which  do  not  clear  up 
with  two  or  three  irrigations  of  the  pelvis  of  the  kidney, 
the  affected  ureter  should  be  catheterized,  the  exciting  organ- 
ism isolated  and  cultured  and  an  autogenous  vaccine  made. 
Injections  of  this  vaccine  (100  million  to  the  dose)  will  often 
give  most  brilliant  results,  and  should  always  be  tried  in  cases 
not  responding  to  treatment.  It  is  of  value  only  in  the  chronic 
cases  and  does  no  good  in  the  acute  ones. 

Surgical  Treatment. — (i)  Decapsulation  of  the  kidney  is 
illogical  and  does  no  good;  (2)  if  pyelitis  is  due  to  stone  in  the 
pelvis,  the  stone  must  be  removed;  (3)  nephrotomy  for  drain- 
age is  required  for  pyelonephrosis  or  (4)  nephrectomy  if  the 
kidney  is  badly  diseased  or  tubercular. 

Prognosis. — A  simple  pyelitis  will  last  for  a  long  time  with- 
out involving  the  kidney  parenchyma,  but  may  do  so  at  any 
time.  Most  cases  yield  readily  to  irrigation  of  the  pelvis  of 
the  kidney;  unilateral  cases  have  fewer  complications  than 
bilateral;  a  quiescent  pyelitis  is  likely  to  be  lighted  up  by  preg- 
nancy or  pelvic  operations. 


292  DISEASES    OF    THE    URINARY   TRACT 

STONE  IN  THE  KIDNEY 

Stone  in  the  kidney  gives  the  same  symptoms  in  both  sexes, 
though  they  are  less  frequent  in  women,  and  a  discussion  of 
their  symptoms  and  treatment  belongs  in  works  on  general 
surgery. 

TUBERCULOSIS  OF  THE  KIDNEY 

This  is  of  two  types:  (i)  Ascending  infection  (more  common 
in  men) ;  (2)  descending  infection  (hematogenous)  representing 
two-thirds  of  the  cases  and  more  common  in  women,  and  most 
often  secondary  to  a  lesion  elsewhere,  notably  in  the  lung. 

Sjmiptoms  are  those  of  pyelitis  and  cystitis. 

Diagnosis  is  made  by  cystoscopy,  which  shows  a  dilated, 
retracted  ureteral  orifice,  usually  with  ulceration  of  the  bladder 
wall  around  it.  The  affected  ureter  is  catheterized  and  the 
urine  secured  is  sedimented  and  examined  for  tubercle  bacilli. 
In  doubtful  cases,  a  guinea-pig  is  injected  (usually  in  the  peri- 
toneal cavity).     The  von  Pirquet  test  is  not  positive  proof. 

Treatment.^ — If  there  is  no  active  lesion  elsewhere,  and  the 
disease  is  unilateral,  nephrectomy  with  excision  of  the  ureter, 
is  necessary. 

Prognosis  is  favorable  if  all  the  diseased  tissue  can  be  re- 
moved; unfavorable  if  there  are  active  tubercular  foci 
elsewhere. 

HYPERNEPHROMA 

Hypernephroma  is  the  most  frequent  tumor  of  the  kidney. 
Symptoms  are  (i)  pain;  (2)  hematuria;  (3)  a  tumor  in  the 
kidney  region,  movable  and  behind  the  colon. 

It  gives  early  metastases,  to  the  lungs,  liver  and  bones,  is 
rapidly  malignant. 

Treatment. — Nephrectomy. 

Prognosis  doubtful,  due  to  the  frequency  of  metastases. 

V.  Floating  Kidney 

Floating  kidney  has  been  described  under  the  sequelae  of 
childbirth  (Chapter  XIII). 


CYSTITIS  293 

II.  Diseases  of  the  Ureter 

INFLAMMATION 

Is  always  secondary  to  pyelitis  or  cystitis.  There  are  two 
forms:  (i)  dilated — where  the  ureter  is  dilated  and   tortuous; 

(2)  fibroid  form  where  the  ureter  is  thick,  straight,  and  has 
numerous  strictures. 

Diagnosis.^ — (i)  Symptoms  of  pyelitis  or  cystitis  usually  mask 
any  from  the  ureter;  (2)  the  thickened  ureter  can  sometimes 
be  palpated  through  the  vaginal  vault;  (3)  the  cystoscope 
shows  an  eroded,  red,  pouting  ureteral  orifice,  with  cloudy 
urine  issuing  from  it. 

Treatment^ — is   that  of  the   causative  pyelitis  or  cystitis. 

STONE  IN  THE  URETER 

Stones  in  the  ureter  are  renal  calculi,  small  enough  to  enter 
the  ureter  and  pass  down  it  to  the  bladder. 

Symptoms. — (i)  Violent  pain,  referred  into  the  pelvis;  (2) 
blood  and  pus  in  the  urine;  (3)  ureteral  catheterization  shows 
an  obstruction;  (4)  x-Ya.y  will  show  the  stone. 

Treatment. — (i)  During  the  acute  attack  hot  fomentations 
to  the  affected  side;  (2)  morphin  hypodermically;  (3)  if 
complete  obstruction  to  the  flow  of  urine,  immediate  operation; 
(4)  if  the  ureter  is  not  completely  blocked,  cystoscopy  with 
catheterization  of  the  ureter  and  injection  of  sterile  sweet  oil; 

(3)  if  the  oil  does  not  dislodge  the  stone,  operation  with,  if 
practicable,  extraperitoneal  incision  of  the  ureter. 

III.  Diseases  of  the  Bladder 

CYSTITIS 

Cystitis  is  caused  by  invasion  of  bacteria  and  their  entry 
into  the  bladder  wall  through  a  break  in  the  lining  epithelium. 
The  presence  of  bacteria  in  the  urine  does  not  mean  cystitis, 
unless  accompanied  by  the  products  of  inflammation  (leuko- 
cytes, ropy  sediment  and  epithelium). 

Routes  of  Infection. — (i)  By  the  urethra,  either  by  sponta- 
neous ascending  infection  (possible  theoretically  at  least)  or 
much  more  likely  catheterization;   (2)   hematogenous  infec- 


294  DISEASES    OF   THE   URINARY   TRACT 

tion;  (3)  lymphatic  infection;  (4)  fistula  (vesicovaginal, 
vesico-intestinal  or  rupture  of  a  cyst  or  pus  tube). 

Causes. — Predisposing  causes  are  lowered  resistance  from :  (i) 
cold;  (2)   physical  exhaustion;   (3)  chronic  pelvic  congestion; 

(4)  irritating  drugs  (cantharides) ;  (5)  ammoniacal  urine,  as 
in  a  cystocele. 

Exciting  Causes. — (i)  Catheterization,  either  by  a  dirty 
catheter  or  by  carrying  organisms  from  the  external  genitalia 
into  the  bladder  by  means  of  the  catheter;  (2)  injuries  of  the 
bladder  in  labor,  or  in  operations,  such  as  cystocele  or  hysterec- 
tomy; (3)  foreign  bodies,  inserted  accidentally  or  for  mas- 
turbation; (4)  infection  through  blood  or  lymph  or  by  ascend- 
ing urethral  infection  in  cases  of  lowered  resistance;  (5) 
by  descending  infection  from  the  kidney. 

Kinds. — (i)  Acute;  (2)  chronic. 

Site  of  infection  may  be  anywhere  in  the  bladder;  the  trigone 
being  the  most  and  the  vertex  the  least  common  situation. 

Pathology.- — i.  Acute  Form:  (i)  Mucosa  red;  (2)  vessels 
enlarged  and  tortuous;  (3)  edema  of  the  mucosa,  with  ecchy- 
moses,  most  marked  in  the  trigonum;  (4)  in  the  later  stages, 
necrosis  of  the  epithelium  with  ulcers,  false  membrane  or 
extensive  sloughs;  (5)  rarely  gangrene  with  secondary  shrink- 
ing in  healing. 

2.  Chronic  Form. — (i)  Mucosa  reddened  in  circumscribed 
areas;  (2)  vessels  enlarged  and  tortuous;  (3)  edema  of  the  trigo- 
num; (4)    epithelial   proliferation    with   polypoid  elevations; 

(5)  areas  of  simple  ulceration,  most  commonly  at  or  near  the 
trigone;  (6)  diminished  capacity  from  contraction  of  the 
wall. 

S3miptoms.' — Acute  Form:  (i)  Severe  pain  in  lower  abdo- 
men; (2)  fever;  (3)   leukocytosis;   (4)   dysuria;   (5)  tenesmus; 

(6)  frequency  of  urination;  (7)  pyuria;  (8)  urine  usually 
neutral  or  alkaline.  The  pain  often  radiates  into  the  vagina 
or  legs.  Dysuria  is  most  severe  before  urination  and  relieved 
by  the  act;  in  this  it  differs  from  urethritis,  where  it  is  most 
severe  during  the  act. 


CYSTITIS  295 

Course  of  Acute  Cystitis. — Acute  cystitis  usually  subsides 
completely  under  treatment,  and  does  not  often  persist  in  a 
chronic  form. 

Symptoms  of  Chronic  Cystitis. — (i)  Frequent  urination;  (2) 
pain  just  before  urination;  (3)  moderate  tenesmus;  (4)  cloudy 
urine;  (5)  ropy  mucopurulent  sediment;  (6)  bleeding  only 
if  due  to  stone,  papilloma  or  cancer. 

Course  of  Chronic  Cystitis.^ — Chronic  cystitis  is  often  very 
intractable  and  resists  treatment  and  often  recurs  after  appar- 
ent cure. 

Diagnosis. — Acute  cystitis  is  made  sufhciently  clear  by  its 
symptoms  alone  and  cystoscopy  is  contra-indicated;  chronic 
cystitis  can  be  diagnosed  with  certainty  by  cystoscopy. 
Through  the  cystoscope  the  vessels  are  seen  enlarged  and  tor- 
tuous, the  bladder  mucosa  reddened  and  dull,  and  in  patches 
puffy  and  edematous.  Ulcers  are  common,  and  stalactites  of 
mucopus  hang  from  the  bladder  wall.  The  diagnosis  should 
not  be  made  from  cloudy  urine  alone  unless  pus  is  found  micro- 
scopically, as  the  cloudy  appearance  of  freshly  passed  urine 
is  often  only  phosphates  or  urates. 

Prophylaxis. — Many  cases  can  be  avoided  by  proper  care 
during  operations  and  above  all  by  proper  technic  of  catheteri- 
zation, a  safe  technic  of  which  is  described  in  the  beginning  of 
this  chapter;  with  the  elimination  of  these  two  causes,  cystitis 
is  a  rare  affection. 

Treatment.^ — i.  Acute  Cases:  (i)  Rest  in  bed;  (2)  milk 
diet;  (3)  hot  water  bag  constantly  over  the  bladder  region; 

(4)  large  amounts  of  water  by  mouth  (12-15  glasses  a  day); 

(5)  uro tropin  15  grains,  acid  sodium  phosphate  or  benzoate 
of  soda  ID  grains  four  times  a  day.  Urotropin,  cystogen  or 
helmitol  are  given  in  as  large  doses  as  the  patient  can  take 
without  bladder  irritation.  The  benzoate  of  soda  is  given  to 
acidulate  the  urine,  so  that  the  formaldehyd  contained  in  the 
urinary  antiseptics  is  freed.  This  will  not  occur  if  the  urine 
is  alkaline.  (6)  All  forms  of  local  treatment  of  the  bladder  are 
con  train  dicated  in  acute  cystitis;  irrigation  is  done  only  when 


296  DISEASES    OF   THE   URINARY   TRACT 

the  acute  symptoms  have  passed.  For  relief  of  pain  it  is  best 
to  use  codein  suppositories  \'2  grain  and  not  hypodermics  of 
morphin.  If  hypodermics  are  required  the  best  are  codein 
sulphate  gr.  3^^  or  hyoscin  gr.  Hoo  or  heroin  gr.  3^^ 2- 

Chronic  Cases. — (i)  Any  cause  that  can  be  found  is  removed; 
(2)  descending  infection  from  the  kidney  is  excluded,  by 
cystoscopy;  (3)  bland  diet;  (4)  urinary  antiseptics  (helmitol, 
gr.  15  four  times  daily  with  benzoate  of  soda  10  grains  if  the 
urine  is  neutral  or  alkaline;  (5)  large  amounts  of  water;  (6) 
if  there  is  much  frequency  of  urination,  a  useful  prescription 
is: 

I^.      Tinct.  belladonna 3i 

Potass,     citratis 3  ii 

Liq.    potass,    citratis q.  s.  ad.    5  iii 

M.     Sig.     Two  teaspoonsful  in  water  four  times  daily. 

(7)  bladder  irrigation  and  instillation. 

Technic  of  Bladder  Irrigation. — Apparatus :  a  four-ounce  glass 
or  metal  funnel,  to  which  eighteen  inches  of  rubber  tubing  is 
attached.  This  is  in  turn  attached  by  a  glass  connection  to  a 
number  17  F.  (6  American)  soft  rubber  catheter.  The  whole 
is  boiled  before  use. 

1.  The  patient  is  arranged  in  the  dorsal  position,  the  vesti- 
bule carefully  cleaned  by  cotton  pledgets  and  lysol  solution, 
the  labia  separated  by  the  fingers  of  one  hand  and  the  catheter 
passed  into  the  urethra. 

2.  The  urine  in  the  bladder  is  drained  off. 

3.  The  funnel  is  filled  with  solution,  which  runs  into  the 
bladder.  Four  ounces  at  a  time  are  poured  in,  until  the  pa- 
tient feels  a  strong  desire  to  empty  the  bladder.  The  best 
solution  is  10  grains  to  the  ounce  boric  acid  solution.  Other 
good  ones  are  nitrate  of  silver  1-6000;  permanganate  of 
potassium  1-5000.     Any  solution  used  should  be  at  no  F. 

4.  The  funnel  is  lowered  and  the  solution  runs  out. 

5.  The  process  is  repeated  three  or  four  times,  till  the  return- 
ing solution  is  perfectly  clear. 

6.  After  the  bladder  is  clean,  2  ounces  of  5  per  cent,  silvol 


CYSTITIS 


297 


solution,  or  25  per  cent,  argyrol  or  i  per  cent,  hegonon  are 
introduced  with  the  same  funnel  and  catheter  and  the  patient 
is  told  to  retain  it  as  long  as  possible  (several  hours  if  she 
can). 

7.  Irrigations  are  repeated  daily,  but  not  oftener  than  once 
a  day.  Usually  a  course  of  treatment  will  last  two  to  four 
weeks. 

8.  Irrigation  is  useless  in  tubercular  cystitis. 

9.  The  criteria  for  cure  are:   (i)  The  patient's  subjective 


Pig.  134. — Apparatus  for  irrigation  of  the  bladder,  consisting  of  a 
catheter,  glass  connection,  rubber  tube  and  a  metal  four-ounce  funnel. 
A  glass  funnel  is  too  liable  to  crack  in  boiling. 

symptoms;  (2)  the  condition  of  the  urine;  (3)  the  appearance 
of  the  bladder  wall  through  a  cystoscope. 

Consequences  of  Chronic  Cystitis,  (i)  Ulcers.- — Unless 
these  disappear  under  the  irrigation  treatment  described  above, 
they  can  be  treated  by  local  treatment  through  an  air  disten- 
tion cystoscope,  with  the  patient  in  the  exaggerated  Trendelen- 


298  DISEASES    or    THE    URINARY    TRACT 

burg  or  knee-chest  posture.  Twenty  grains  to  the  ounce 
nitrate  of  silver  is  applied  directly  to  the  ulcer,  on  an 
applicator. 

(2)  Contracted  bladder  is  not  uncommon  from  the  cicatrices 
of  ulceration  or  from  habit  of  frequent  urination.  It  is  very 
annoying  to  the  patient,  due  to  frequent  urination. 

Treatment. — (i)  The  patient  and  apparatus  are  prepared  as 
for  irrigation;  (2)  after  the  catheter  is  inserted  in  the  bladder, 
sterile  water  is  allowed  to  flow  in,  by  gravity,  until  the  patient 
complains  of  uncomfortable  distention;  (3)  then  2  ounces 
more  are  inserted  and  the  patient  made  to  retain  this  for  one- 
half  hour  if  possible;  (4)  this  procedure  is  repeated  daily, 
gradually  increasing  the  amount  of  water  as  it  can  be  retained ; 
(5)  the  treatment  should  be  kept  up  until  32  ounces  can 
be  introduced  and  retained;  this  process  taking  from  three 
to  six  weeks;  (6)  the  patient  is  told  to  empty  the  bladder 
only  three  times  daily  as  a  maximum,  to  avoid  reforming  the 
habit  of  frequent  urination. 

In  very  severe  cystitis,  resisting  other  treatment,  it  may  be 
necessary  to  secure  constant  drainage  by  artificial  vesicovaginal 
fistula.  The  incision  is  made  in  the  middle  of  the  anterior 
vaginal  wall,  two-thirds  of  the  way  to  the  cervix.  The  inci- 
sion is  three-quarters  of  an  inch  long  and  the  bladder  and 
vaginal  mucosa  are  sewed  together,  to  prevent  premature 
closure.  The  bladder  is  irrigated  through  the  fistula  twice 
daily  with  boric-acid  solution.  A  permanent  fistula  is  not 
to  be  feared.  The  fistula  has  a  strong  tendency  to  close  spon- 
taneously, and  when  the  symptoms  have  subsided,  the  opera- 
tion of  closure  is  always  successful,  as  there  has  not  been  the 
sloughing  seen  in  traumatic  fistula. 

Cystitis  Vetularum  (old  women)  is  a  common  affection, 
due  to  shrinking  and  gaping  of  the  external  orifice  and  direct 
invasion  of  bacteria  through  the  urethra.  There  is  great 
frequency  of  urination  and  often  incontinence.  The  only 
relief  is  irrigation  of  the  bladder  with  hot  boric-acid  solution, 
followed  by  §ss.  of  25  per  cent,  argyrol  or  5  per  cent,  silvol 


PAPILLOMA    or   THE   BLADDER  299 

solution  repeated  as  infrequently  as  is  compatible  with  reason- 
able comfort. 

TUBERCULOSIS  OF  THE  BLADDER 

This  is  always  secondary  to  some  primary  focus  elsewhere, 
nearly  always  from  the  kidney.  The  affection  in  the  bladder 
usually  appears  as  ulcers  of  the  trigone,  especially  around  the 
ureter  of  the  affected  side.  The  corresponding  kidney  is 
searched  for  evidence  of  tuberculosis,  as  already  described. 

Treatment.^ — Nephrectomy,  provided  the  disease  is  uni- 
lateral. The  bladder  ulcers  will  disappear  -spontaneously 
after   nephrectomy,   while   no   other  treatment  affects  them. 

If  the  disease  is  bilateral,  or  if  there  is  active  tuberculosis 
elsewhere,  operation  is  contraindicated. 

PAPILLOMA  OF  THE  BLADDER 

Papilloma  is  the  most  frequent  tumor  of  the  bladder.  They 
are  pedunculated,  vary  in  size  from  a  pea  to  the  clinched  fist. 
They  are  usually  multiple,  three  or  four  being  the  commonest 
number,  and  may  be  widely  disseminated  over  the  interior 
surface  of  the  bladder. 

Structure. — A  connective- tissue  stalk,  very  vascular,  covered 
with  numerous  layers  of  epithelium;  hence  their  origin  from 
the  bladder  epithelium.  They  are  often  partly  or  entirely 
encrusted  with  urinary  salts,  and  for  this  reason,  may  be 
mistaken  for  stones  in  cystoscopic  examination. 

They  should  be  regarded  as  malignant,  and  should  be  re- 
moved as  completely  as  possible. 

Symptoms. — (i)  Hematuria;  (2)  all  symptoms  of  chronic 
cystitis,  frequency,  tenesmus,  etc. ;  (3)  if  the  papilloma  is  in  the 
trigone,  sudden  interruptions  of  the  stream  of  urine. 

Diagnosis  is  made  by  cystoscopic  examination. 

Treatment. — (i)  Fulguration,  through  a  cystoscope.  Several 
appHcations  of  the  current,  three  or  four  days  apart  are 
required.  This  is  the  best  method,  except  in  very  large 
papillomata. 


300  DISEASES    OF    THE    URINARY    TRACT 

(2)  Removal  by  a  wire  snare,  through  an  operating  cys- 
toscope.  This  is  much  more  difficult  and  not  as  satisfactory 
as  fulguration. 

(3)  Vaginal  cystotomy,  in  very  large  growths. 

(4)  Suprapubic  cystotomy,  in  very  large  growths.  This  is 
better  than  vaginal  cystotomy,  because  of  the  greater  room  for 
dealing  with  hemorrhage  which  may  be  very  profuse  and  re- 
quire packing  of  the  bladder  with  gauze. 

(5)  In  large  growths,  necessitating  vaginal  or  suprapubic 
cystotomy,  the  most  satisfactory  technic  is  to  open  the 
bladder,  remove  the  papilloma  with  a  heavy  wire  or  chain 
snare,  and  then  fulgurate  the  base.  In  this  way  the  bleed- 
ing is  minimized. 

Prognosis. — Papillomata  often  recur  as  carcinoma  of  the 
bladder  wall,  and  patients  should  be  regularly  cystoscoped 
every  two  months  over » a  period  of  three  years,  so  that  any 
area  can  be  fulgurated  in  the  early  stage. 

CANCER  OF  THE  BLADDER 

•  Cancer  of  the  bladder  is  rare.  It  is  of  two  kinds :  (i)  Primary; 
(2)  secondary  to  cancer  of  the  cervix.  Primary  cancer  of  the 
bladder  occurs  as  (i)  medullary;  (2)  scirrhous;  (3)  squamous 
epithelial;  (4)  papillary.  It  tends  to  perforate  the  bladder 
wall  into  the  vagina,  and  gives  metastasis  to  the  deep  pelvic 
lymphatics. 

Symptoms. — (i)  Hematuria,  at  first  intermittent,  later  con- 
stant, with  severe  secondary  anemia;  (2)  Severe  cystitis. 

Diagnosis  is  made  by  cystoscopic  examination,  when  the 
ragged  infiltrated  area  can  be  seen,  if  there  is  not  so  much 
bleeding  that  the  fluid  in  the  bladder  is  opaque. 

Treatment. — (i)  Papillary  masses  may  be  fulgurated  or 
removed  by  the  suprapubic  route;  (2)  if  far  advanced,  it  is 
inoperable;  (3)  secondary  invasion  from  the  cervix  is  always 
inoperable;  (4)  total  extirpation  of  the  bladder,  with  ureteral 
implantation  in  the  bowel  or  vagina,  has  a  very  high  primary 
mortality,  and  secondary  pyonephrosis  is  almost  inevitable. 


VESICO-URETHRAL   FISSURE  301 

STONE  IN  THE  BLADDER 

Stone  in  the  bladder  is  much  less  common  in  women,  stone  in 
men  being  two  hundred  times  more  frequent.  This  is  due  to 
the  short,  wide,  dilatable  urethra  of  the  female,  allowing  small 
vesical  or  renal  stones  to  escape  before  they  have  any  chance 
to  increase  in  size. 

Stones  are  formed  by  crystalHzation  of  urinary  salts  and 
are  composed  of  phosphates,  oxalates,  ammonium  urates, 
carbonates,  uric  acid,  cystin  and  xanthin. 

Cystitis  and  ammoniacal  urine  are  favorable  etiologic  fac- 
tors. They  always  form  about  any  foreign  body,  such  as  hair- 
pins, nails,  etc.,  which,  introduced  into  the  urethra  for  purposes 
of  masturbation,  have  slipped  into  the  bladder. 

Probably  the  commonest  nucleus  for  stone  is  a  suture  of 
permanent  material  penetrating  the  bladder  in  an  operation 
for  cystocele. 

Site. — (i)  Free  in  the  bladder;  (2)  impacted  in  diverticula; 
(3)  fixed  in  the  urethra  or  ureteral  orifice. 

Symptoms.^ — (i)  Hematuria;  (2)  cystitis,  usually  severe. 

Diagnosis.^ — (i)  May  be  felt  by  bimanual  examination;  (2) 
a  sound  in  the  bladder,  will  give  the  usual  metallic  click  when 
it  touches  the  stone;  (3)  :^;-ray;  (4)  cystoscopy,  the  most  reliable 
of  all. 

Treatment.^ — (i)  If  small,  the  stone  can  be  drawn  out 
through  a  cystoscope;  (2)  if  impacted  in  the  ureteral  orifice 
it  can  be  dislodged  and  removed;  (3)  large  stones  can  be 
crushed  by  a  lithotrite  and  washed  out  by  the  evacuating 
apparatus;  (4)  stones  too  hard  or  large  to  be  crushed,  or 
those  so  impacted  in  a  diverticulum  that  they  cannot  be  dis- 
lodged, may  be  removed  by  vaginal  cystotomy,  or  by  supra- 
pubic extraperitoneal  cystotomy. 

VESICO-URETHRAL  FISSURE 

Vesico-urethral  fissure  is  a  linear  ulcer,  beginning  in  the 
trigone  and  running  through  the  vesical  sphincter  into  the 
floor  of  the  urethra,  parallel  with  its  long  diameter.     One- 


302  DISEASES    OF   THE   URINARY   TRACT 

third  of  the  length  is  in  the  bladder,  two-thirds  in  the 
urethra. 

Cause. — (i)  Gonorrheal  urethritis;  (2)  cystitis;  (3)  passage 
of  a  stone  with  sharp  edge;  (4)  injuries  during  cystoscopy. 

Symptoms.^ — (i)  Frequency  of  urination;  (2)  burning  on 
urination;  (3)  pus  or  blood  in  urine;  (4)  intense  pain  just  at  the 
end  of  urination,  the  stream  being  followed  by  one  or  two  drops 
of  blood. 

Diagnosis.- — The  linear  ulcer  can  be  seen  plainly  through  a 
cystoscope  or  urethral  endoscope. 

Treatment. — (i)  Injections  of  cocain  solution,  4percent.,  into 
the  urethra;  (2)  dilatation  of  the  urethra  up  to  a  42  sound;  (3) 
repetition   every   other   day  for   three   or   four   treatments. 

-    EXSTROPHY  OF  THE  BLADDER 

This  is  due  to  a  defect  of  development  of  the  anterior  abdom- 
inal and  bladder  walls  and  symphysis,  so  that  the  interior 
of  the  bladder  is  exposed. 

If  the  upper  part  of  the  bladder  alone  is  exposed  it  is  called 
superior  vesical  fissure.  If  the  lower  part  of  the  bladder  alone 
is  exposed  it  is  called  inferior  vesical  fissure.  If  the  urethra 
alone  is  involved  it  is  called  epispadias. 

Treatment  is  directed  toward  control  of  incontinence,  and  is 
accomplished  by  plastic  surgery,  flaps  being  taken  from  the 
abdominal  wall,  planned  to  meet  the  needs  of  the  individual 
case.  Repeated  operations  are  the  rule,  and  complete  success 
is  rare. 

OVERDISTENTION  OF  THE  BLADDER 

Overdistention  of  the  bladder  is  common  in  women.  It  is 
due  to  (i)  Pelvic  tumors;  (2)  neurosis;  (3)  pregnancy  with 
backward  displacement  of  the  uterus;  (4)  pressure  in  labor. 
The  distended  bladder  causes  a  cystic  tumor  in  the  lower  abdo- 
men, easily  mistaken  for  an  ovarian  cyst;  there  is  often  fre- 
quent urination  or  a  constant  dribbling. 

Treatment  is  catheterization  with  a  silk  or  wax  catheter,  and 
not  a  glass  one,  which  latter  is  too  short  and  too  easily  broken. 


DISEASES    OF   THE    URETHRA  303 

No  diagnosis  as  to  the  nature  of  a  cystic  tumor  should  ever  be 
made  until  the  bladder  has  been  emptied  by  catheter  and  not 
voluntarily. 

IV.  Diseases  of  the  Urethra 

1.  Congenital  defects  as  epispadias  and  hypospadias.  The 
former  is  associated  with  exstrophy  of  the  bladder.  Hypo- 
spadias may  be  partial  or  complete.  Incontinence  always 
accompanies  the  complete,  and  in  these  cases  there  is  a  funnel- 
shaped  opening,  apparently  communicating  with  the  vagina, 
but  really  opening  into  the  vestibule.  The  sphincter  is 
absent. 

Treatment  is  plastic  operation,  the  success  of  which  is  doubt- 
ful. Complete  success  can  only  be  attained  when  there  is  a 
partial  defect  and  the  sphincter  is,  in  part  at  least,  present. 

2.  Stricture  and  Atresia. — Both  are  less  common  in  women. 
The  stricture  is  usually  at  the  upper  third,  near  the  bladder. 

Causes. — (i)  Injuries  of  childbirth;  (2)  caustics  applied  in 
treatment;  (3)  cicatricial  bands;  (4)  disuse  in  fistulae;  (5) 
congenital. 

Symptoms  are  (i)  dysuria;  (2)  frequent  urination. 

Diagnosis  is  made  by  catheterization  or  sounding,  when  the 
obstruction  is  obvious. 

Treatment  is  gradual  dilatation  by  sounds,  up  to  42.  Incision 
is  rarely  if  ever  necessary. 

3.  Acute  Urethritis. — Acute  urethritis  is  exclusively  gonor- 
rheal, and  is  of  short  duration. 

Symptoms. — (i)  First  discomfort,  then  burning  on  urination; 
(2)  meatus  is  swollen, hyper emic,  everted;  (3)  orifices  of  Skene's 
glands  are  marked  by  erosion;  (4)  thick  yellow  purulent 
discharge. 

Prognosis. — (i)  Heals  quickly  and  spontaneously  or  (2) 
passes  into  the  chronic  stage. 

Treatment  is  given  in  Chapter  XV,  on  gonorrhea. 

4.  Chronic  Urethritis.  Causes. — (i)  Persistence  after  acute 
attack;  (2)  infection  by  other  organism,  notably  colon  bacillus 
or  staphylococcus. 


304  DISEASES    OF   THE   URINARY   TRACT 

Site. — It  is  localized,  usually  in  Skene's  glands,  and  does  not 
involve  the  whole  canal. 

Symptoms. — (i)  Burning  and  pain  during  urination;  (2)  a 
thin  scanty  purulent  discharge. 

Diagnosis. — (i)  Meatus  is  everted  and  edematous;  (2) 
orifices  of  Skene's  glands  are  eroded;  (3)  pressure  on  or  milking 
of  urethra  will  yield  a  drop  or  two  of  pus. 

Treatment. — (i)  Obliteration  of  Skene's  glands,  failing  which 
a  cure  is  unlikely;  (2)  applications  of  30  grains  to  the  ounce 
nitrate  of  silver  solution  to  the  canal,  best  by  injection  with  a 
medicine  dropper,  every  three  days;  (3)  irrigation  of  the 
urethra,  with  boric  acid  solution,  once  daily  through  Skene's 
reflex  catheter;  (4)  instillations  into  the  urethra,  every  other 
day,  of  silvol  ointment  5  per  cent. ;  argentide  paste  20  per  cent, 
or  25  per  cent,  argyrol  or  3  per  cent,  protargol  in  glycerin. 

Treatment  requires  time  and  patience,  as  the  disease  is 
stubborn. 

Consequences. — (i)  Peri-urethral  or  suburethral  abscess 
(see  Chapter  IV);  (2)  granular  erosion  of  urethra,  where  the 
mucosa  is  papillary,  bright  red  and  very  sensitive. 

Treatment. — (i)  As  described  in  the  treatment  of  chronic 
urethritis;  (2)  artificial  vesicovaginal  fistula,  for  drainage, 
hastens  a  cure. 

5.  Urethral  caruncle,  described  in  Chapter  IV,  number  16. 

6.  Prolapse  of  the  mucosa,  described  in  Chapter  IV, 
number  17. 


CHAPTER  XV 
GONORRHEA 

Gonorrhea  is  an  acute  contagious  disease,  caused  by  the 
gonococcus;  a  biscuit-shaped  diploccccus,  Gram  negative, 
staining  by  the  ordinary  methods,  and  found  in  the  purulent 
discharge  both  free  and  intracellular. 

I.  Mode  of  Infection. — Except  in  the  case  of  young 
children,  where  it  is  transferred  indirectly,  it  is  transmitted 


Fig.  135. — Diplococcus  of  Neisser,  the  gonorrhea  germ,  taken  from  the 
pus  of  the  eye.  The  little  dots  are  gonococci,  the  large  masses  are  pus 
cells.     {De  Lee.) 

almost  exclusively  by  sexual  intercourse.     Rarely  it  may  be 
spread  by  towels,  napkins,  douche  nozzles  or  other  foreign 
bodies,  used  by  an  infected  person.     A  common  type  of  case  is 
20  305 


3o6  GONORRHEA 

infection  of  the  wife  by  a  husband  who  has  had  gonorrhea,  but 
who  was  supposed  to  be  cured.  The  congestion  and  stimulus 
of  intercourse  will  often  light  up  an  attack  which  under 
ordinary  conditions  gives  no  indication  of  its  presence.  It 
cannot  be  considered  safe  for  a  man  to  marry  until  at  least 
one  year  after  the  disappearance  of  all  symptoms. 

2.  Variations  under  Culture. — The  gonococcus  is  purely  a 
human  organism.  It  is  not  found  in  other  animals,  and  can- 
not be  inoculated  on  other  than  human  tissues.  It  will  grow 
only  in  media  made  from  human  tissues;  it  will  not  grow  on 
bouillon  or  other  animal  culture  media.  It  can  be  cultured 
through  numerous  generations,  gradually  losing  virulence,  but 
when  introduced  into  the  human  body,  rapidly  regains  its  lost 
virulence.  It  is  infectious  only  in  the  moist  state  and  grows 
only  in  the  presence  of  moisture;  if  dried,  it  soon  dies. 

3.  Habitat. — The  gonococcus  is  particularly  partial  to 
columnar  epithelium,  where  it  dwells  superficially  and  between 
the  cells.  It  does  not  often  involve  the  glands  (of  the  cervix, 
uterus  or  Bartholin)  but  remains  in  their  ducts.  No  abrasion 
of  the  surface  is  necessary  for  infection.     Extragenitally,  the 

commonest    site    of    infection    is 

M   M  «»  S      the  eye.     It  rarely  penetrates  the 

w9    %9     «p  «p      blood-  and    lymph-channels,  but 

Pig.     136.— Indicating    the    may    do    SO,  and  localize  in   the 

shape  of  the  dipiococcus  of  gon-    jq^j^^,  ^^^  valves  of  the  heart.     It 

orrhea  (gonococcus).      {N orris.)     ■' 

requires  a  moist  surface,  prefer- 
ably columnar  epithelium,  with  good  blood-supply.  The 
incubation  period,  from  inoculation  to  the  appearance  of 
symptoms,  is  four  days  to  a  week. 

4.  Growth. — No  break  in  the  epithelium  is  needed.  The 
gonococcus  is  at  first  piled  on  the  surface,  then  penetrates  to 
the  deeper  layers  through  the  interstices  between  the  cells 
of  the  surface  epithelium,  and  when  once  under  the  surface, 
it  is  extremely  difficult  to  eradicate. 

5.  Latency. — When  confined  in  a  closed  sac,  like  a  pyosal- 
pinx,  the  gonococcus  soon  dies;  when  in  gland  ducts  it  remains 


DIAGNOSIS  307 

active  for  very  long  periods.  It  may  remain  latent  for  years,  so 
that  the  patient,  though  infected,  shows  no  symptoms,  and 
suddenly  light  up  into  active  virulence,  because  of  local  hypere- 
mia from  excessive  intercourse,  menstruation,  childbirth,  etc. 
The  average  period  of  latency  is  four  or  five  years;  longer 
periods  are  probably  fresh  inoculations,  as  the  gonococcus  does 
not  confer  immunity  against  successive  attacks. 

6.  Order  of  Infection. — In  the  genitalia,  the  order  of  infec- 
tion is  approximately  as  follows:  (i)  The  urethra;  (2)  cervix,  at 
about  the  same  time;  (3)  Skene's  and  Bartholin's  glands; 
(4)  endometrium;  (5)  tubes;  (6)  peritoneum. 

7.  Lurking  places  of  gonorrhea,  in  chronic  cases  are:  (i) 
Skene's  glands;  (2)  Bartholin's  glands;  (3)  ducts  of  the  cervical 
glands;  (4)  patches  in  the  endometrium;  (5)  rugae  in  the  folds 
of  the  tubal  mucosa,  provided  there  is  no  pyosalpinx. 

The  annoying  and  persistent  leukorrhea  in  a  case  of  chronic 
gonorrhea  is  almost  exclusively  from  the  cervix. 

8.  Diagnosis. — If  a  patient  presents  herself  with  complaint 
of  burning  on  micturition,  with  profuse  purulent  vaginal 
discharge  and  examination  shows  the  skin  of  the  vulva  red  and 
chafed,  covered  with  a  yellow,  creamy,  leukorrheal  discbarge, 
the  urethral  orifice  red  and  angry,  exuding  a  few  drops  of  pus 
when  milked;  the  cervix  eroded  and  the  source  of  discharge, 
a  presumptive  diagnosis  of  gonorrhea  is  amply  justified,  and 
easily  confirmed  by  the  microscope.  In  cases  past  the  acute 
stage,  or  of  long  standing,  an  accurate  diagnosis  may  be 
extremely  difficult,  and  depends  finally  upon  microscopical 
examination  of  smears  made  from  the  discharge. 

Preparation  of  a  Smear. — (i)  The  patient  is  arranged  in  the 
dorsal  position,  and,  except  in  acute  cases,  has  been  told  to 
take  no  douche  for  the  twenty-four  hours  preceding  the 
examination;  (2)  pressure  is  made  along  the  urethra,  from 
behind  forward,  and  if  a  drop  of  pus  appears  in  the  orifice,  it  is 
taken  up  on  a  small  pledget  of  cotton  on  an  applicator,  and 
transferred  to  the  surface  of  a  clean  glass  slide. 

A  slide  is  better  than  a  cover  glass,  unless  permanent  speci- 


3o8  GONORRHEA 

mens  are  desired,  because  it  gives  a  wider  field  for  examination 
and  is  more  easily  handled.  A  second  slide  is  placed  upon 
the  first  and  the  two  are  then  slid  apart,  to  ensure  an  even, 
thin  distribution  of  the  discharge. 

3.  The  cervix  is  exposed  through  a  bivalve  speculum,  any 
discharge  visible  is  caught  and  prepared  in  the  same  way. 

Staining  is  best  done,  except  in  doubtful  cases,  with  i  per 
cent,  fresh  aqueous  methylene  blue;  (i)  after  the  slide  is  dry,  it 
is  held  in  forceps  and  the  surface  flooded  with  the  stain;  (2) 
it  is  gently  heated  (so  that  it  steams  but  does  not  boil)  over  a 
Bunsen  flame  or  alcohol  lamp  for  8  minutes;  (3)  the  stain  is 
poured  off,  the  slide  washed  and  dried;  (4)  it  is  examined  with 
a  3'l2"ii^ch  oil-immersion  lens. 

The  nuclei  of  the  pus  cells  are  light  blue,  the  gonococci  very 
dark  blue  (almost  black). 

Doubtful  cases  are  stained  by  the  Gram  method,  in  which 
case  the  gonococci,  being  Gram-negative,  are  not  stained. 

Technic  (Tiedemann's  Modification). — (i)  The  slides  are 
prepared  as  usual. 

2.  The  slide  is  flooded  with  2  per  cent,  alcoholic  solution 
of  crystal  violet,  allowed  to  act  for  fifteen  seconds. 

3.  The  slide  is  slowly  washed  off  by  water  dropping  from  a 
pipet  (about  ten  seconds). 

4.  Flood  slide  with  solution  of  iodin  i  gram,  potassium 
iodid  2  grams,  distilled  water  100  mil  and  allow  to  act  for 
fifteen  seconds. 

5.  Wash  thoroughly,  dry  and  examine  with  H  2 -inch  oil- 
immersion  lens.  Any  diplococci  appearing  in  a  specimen 
stained  in  methylene  blue  and  not  appearing  when  a  second 
slide  is  stained  as  above,  are  almost  certainly  gonococci. 

Doubtful  Cases. — In  old  chronic  cases,  repeated  examinations 
may  fail  to  show  positive  evidence  of  gonococci.  In  such  a 
case  the  diagnosis  must  rest  upon  the  following: 

I.  Tell  patient  to  drink  a  bottle  of  beer  at  night,  and  present 
herself  for  examination  the  next  morning,  without  douching. 
The  irritating  effect  of  alcohol  may  cause  slight  temporary 


GONORRHEA   IN    CHILDREN  309 

activity  in  the  discharge,  sufficient  to  bring  gonococci  to  the 
surface. 

2.  The  complement-fixation  test. 

3.  Search  for  the  stigmata  of  gonorrhea:  (i)  Erosion  of  the 
orifices  of  Skene's  glands;  (2)  erosion  of  the  ducts  of  Barthohn's 
glands;  (3)  erosion  of  the  cervix. 

History  of  previous  infection  in  the  husband;  a  point  re- 
quiring considerable  diplomacy. 

9.  Prognosis. — If  infection  has  travelled  above  the  internal 
OS,  permanent  cure  is  very  rare;  and  in  many  cases  infection  of 
Skene's  and  Bartholin's  glands  and  of  the  glands  of  the  cervix 
resist  treatment  indefinitely.  The  acute  stage  of  gonorrhea 
in  women  lasts  for  a  short  time  only;  the  chronic  stage  lasts 
indefinitely. 

10.  Kinds  of  Gonorrhea. — (i)  Acute — of  short  duration  in 
women;  (2)  chronic — the  type  most  commonly  seen. 

The  treatment  of  both  will  be  described  according  to  the 
region  they  affect. 

11.  Internal  Treatment  and  General  Hygienic  Rules, 
Applicable  to  all  Cases.^ — d)  During  the  acute  stage,  rest  off 
feet  or  in  bed;  (2)  avoid  all  highly  spiced  foods,  and  alcohol  in 
any  form.  Diet  should  be  bland  and  easily  digested ;  (3)  avoid- 
ance of  anything  causing  pelvic  congestion,  particularly  sexual 
intercourse;  (4)  copious  amounts  of  water  daily;  (5)  cleanliness 
of  genitalia;  (6)  if  the  patient  has  burning  on  urination,  give 
bland  diuretics,  such  as  potassium  citrate  2  drams ;  tincture  of 
belladonna  2  drams;  liq.  potass,  citratis  q.  s.  ad.  3  ounces. 
Sig.  Teaspoonful  in  water  four  times  daily;  (7)  if  nervous,  give 
sodium  bromid,  10  grains  four  times  daily;  (8)  every  patient,  or 
person  handling  such  a  patient,  should  be  warned  of  the  danger 
of  ophthalmia,  and  their  hands  should  be  kept  scrupulously 
clean. 

12.  Gonorrhea  in  Children  (Vulvovaginitis). — The  modified 
squamous  epithelium  in  children  is  soft,  delicate,  vascular  and 
moist,  hence  very  susceptible  to  gonorrheal  infection,  which  in 
this  type  of  case  can  be  spread  by  indirect  means. 


310  GONORRHEA 

Method  of  Infection. — (i)  Depraved  sexual  practices;  (2)  con- 
taminated linen,  towels  or  diapers;  (3)  epidemics  in  institutions 
are  often  difficult  to  trace  though  a  clue  may  be  afforded  by  the 
fact  that  the  gonococcus  is  infectious  in  the  moist  state  only. 

Symptoms. — (i)  Swolhn  red  labia;  (2)  severe  chafing  of 
perineum  and  inner  side  of  thighs;  (3)  considerable  pain  and 
tenderness;  (4)  profuse  purulent  yellow  discharge,  in  which 
gonococci  are  found  microscopically. 

The  disease  is  most  often  confined  to  the  vulva,  labia  and 
external  genitalia;  it  only  rarely  involves  the  uterus  and  tubes, 
though  it  may  involve  the  vagina,  causing  ulceration  and  sub- 
sequent adhesion  of  the  opposing  surfaces.  In  a  small 
percentage  of  cases  the  urethra  is  infected. 

Treatment  is  difficult  and  requires  prolonged  effort  and 
patience. 

Prophylaxis  is  possible  only  in  institutions  and  any  suspected 
case  should  be  rigidly  isolated,  until  the  vaginal  discharge 
can  be  proven  innocent.  Nurses  caring  for  suspected  or  actual 
cases  should  also  be  isolated,  and  all  dressings  burned.  Special 
utensils  must  be  kept  for  these  patients. 

Treatment  of  Acute  Stage. — During  the  acute  stage  there  is 
so  much  tenderness  that  treatment  can  be  directed  only  to- 
ward keeping  the  external  genitalia  as  clean  as  possible,  by 
external  irrigation  and  sponging  with  boric  acid  solution  or 
1-5000  potassium  permanganate.  There  is  marked  tendency 
to  desquamation  and  adhesion  of  the  labia;  hence  the  inner 
margins  of  the  labia  should  be  kept  covered  with  boric  acid 
ointment,  until  the  acute  stage  is  past. 

Treatment  of  chronic  stage  is  usually  prolonged,  and  while 
the  uncomfortable  symptoms  can  be  controlled  quickly,  a  cure 
is  a  matter  of  months,  and  relapses  are  frequent. 

1 .  If  the  hymen  is  of  such  a  character  that  it  interferes  with 
the  necessary  treatment,  it  must  be  sacrificed. 

2.  The  vagina  is  dried  out  with  a  thin  strip  of  gauze,  and 
through  a  narrow  speculum  or  endoscope,  is  painted  with  5 
per  cent,  nitrate  of  silver  solution. 


GONORRHEAL   URETHRITIS  311 

3.  A  vaginal  douche  of  1-3000  permanganate  solution  is 
given  twice  daily,  through  a  catheter.  . 

4.  The  external  genitals  are  kept  scrupulously  clean. 

5.  Every  other  day,  the  vagina  and  labia  are  flooded  with 
25  per  cent,  argyrol  solution,  or  25  per  cent,  ichthyol  in  glycerin 
or  ID  per  cent,  silvol  solution,  injected  with  a  medicine  dropper. 

6.  The  child  is  kept  from  active  exercise,  is  given  a  bland 
diet  with  plenty  of  water;  its  underclothes  are  kept  separate 
and  boiled  before  washing,  and  all  contaminated  dressings  are 
burned. 

7.  Vaccirtes  are  useful  in  shortening  the  duration  of  infection. 
Prognosis  of  Chronic  Stage.— Th.t  disease  may  last  for  years, 

in  recurrent  periods;  three  to  six  months  are  necessary  for  the 
disappearance  of  gonococci;  very  young  children  respond  more 
quickly  to  treatment.  Requisite  for  cure  are  four  consecutive 
negative  smears  at  weekly  intervals. 

Complications  of  chronic  stage  are  common,  especially  in 
neglected  cases;  (i)  inguinal  adenitis  (rarely  suppurative); 
(2)  venereal  warts;  (3)  arthritis  (subacute  form);  (4)  ophthal- 
mia, from  hand  infection;  (5)  peritonitis;  (6)  cystitis  and  pye- 
litis (rare). 

Recurrences  are  common,  even  after  an  interval  of  several 
years,  and  are  treated  like  the  original  attack. 

13.  Gonorrheal  urethritis  is  the  commonest  manifestation 
of  primary  infection  in  the  adult,  the  epithelium  of  the  meatus 
being  a  favorable  medium  for  growth  of  the  gonococcus.  The 
disease  is  most  commonly  limited  to  the  lower  one-third  of  the 
urethra,  and  to  Skene's  glands. 

Symptoms. — (i)  The  vestibule  is  red  and  tender;  (2)  the  mea- 
tus is  pouting,  edematous  and  exudes  a  thick  yellow  pus;  (3) 
the  orifices  of  Skene's  glands  are  visible  and  eroded;  (4)  marked 
burning,  with  occasionally  severe  pain,  during  urination;  (5) 
many  cases  produce  negligible  symptoms,  so  that  the  acute 
stage  passes  unnoticed. 

Prognosis. — (i)  The  duration  is  from  three  to  six  weeks, 
though  the  acute  symptoms  last  only  a  few  days. 


312  GONORRHEA 

2.  There  is  slight  danger  of  cystitis,  unless  the  infection  is 
carried  in  by  injudicious  use  of  a  catheter. 

3.  Chronic  urethritis  may  persist  for  years  in  Skene's  glands, 
until  the  ducts  are  destroyed  by  cauterization. 

Treatment. — In  addition  to  the  general  treatment  described 
under  section  eleven  in  this  chapter;  (i)  irrigation  of  the 
urethra  with  boric  acid  solution  or  1-5000  potassium  perman- 
ganate solution,  using  Skene's  reflux  catheter,  and  being  careful 
not  to  push  the  catheter  past  the  internal  sphincter;  (2) 
injection  in  the  urethra  of  5  per  cent,  argyrol  cr  protargol  or 
silvol  in  glycerin,  injecting  only  i  mil  to  avoid  entering  the 
bladder.  The  patient  should  not  urinate  for  at  least  an  hour 
following  the  injection;  (3)  obliteration  of  Skene's  glands,  in 
chronic  cases. 

Complications. — (i)  Abscess  of  Skene's  glands  (see  Chapter 
IV) ;  (2)  stricture,  much  less  common  in  women. 

14.  Vulvovaginitis  in  the  adult  is  rare,  due  to  the  tougher 
character  of  the  epithelium.  At  the  vulva,  inflammation  is 
usually  secondary  to  inflammation  of  Skene's  or  Bartholin's 
glands;  in  the  vaginal  vaults,  it  is  secondary  to  the  cervix. 
Whatever  form  of  treatment  is  instituted,  it  is  essential  that 
every  care  should  be  taken  not  to  extend  infection  highei  up 
in  the  genital  canal,  and  that  no  instruments  or  solution  should 
be  used  which  would  irritate  or  injure  the  epithelial  surface. 

Treatment. — (i)  Through  a  bivalve  speculum,  the  cervix 
and  vaginal  vaults  are  sponged  off  with  cotton  pledgets  soaked 
in  salt  solution  (i  dram  to  the  pint;  to  dissolve  mucus)  and 
then  by  plain  water  to  remove  the  salt. 

(2)  The  cervix  and  vaginal  vaults  are  painted  over  with 
argyrol  solution  25  per  cent,  or  protargol  2  per  cent,  or  silvol 
10  per  cent,  or  nitrate  of  silver  8  per  cent,  and  the  excess 
sponged  out. 

(3)  A  large  tampon,  with  50  per  cent,  ichthyol  in  glycerin, 
or  25  per  cent,  boroglycerid,  is  packed  rather  firmly  in  the 
vaginal  vault;  two  other  dry  tampons  are  packed  in  below 
it  and  the  bivalve  speculum  removed. 


CERVICAL   GONORRHEA  313 

(4)  If  there  is  much  discharge,  the  tampons  are  removed  in 
twelve  hours,  otherwise  in  twenty-four. 

(5)  The  patient  takes  a  douche  of  1-3000  permanganate 
solution  twice  daily  until  the  tampons  are  replaced. 

(6)  The  tampons  are  renewed  every  three  days. 

'  Dry  treatment  consists  of  drying  the  cervix  and  vaginal  vaults 
with  gauze,  through  a  bivalve  speculum,  and  insufflating  a 
powder  (a  satisfactory  one  is  carboHc  acid  2  drams,  burnt  alum 
I  ounce,  boric  acid  3  ounces)  with  a  Politzer  bag.  After  the 
powder  is  blown  in,  a  wool  tampon  heavily  dusted  with  the 
same  powder  is  inserted  and  left  in  place  twenty-four  to  forty- 
eight  hours,  when  it  is  removed  and  the  treatment  is  repeated. 
It  is  satisfactory  only  when  discharge  is  scanty. 

15.  Cervical  gonorrhea  (endocervicitis)  is  either  primary  or 
secondary.  The  cervix  is  involved  in  most  cases  of  gonorrhea 
in  the  adult.  As  the  cervix  is  quite  insensitive,  pain  in  the 
acute  stage  is  absent. 

Symptoms. — i.  Acute  Stage:  (i)  The  cervix  is  red  and 
angry  looking;  (2)  the  external  os  is  eroded;  (3)  the  erosion 
bleeds  easily  to  the  touch;  (4)  there  is  a  profuse  yellow 
purulent  discharge;  (5)  gonococci  are  found  on'  microscopic 
examination. 

Treatment. — It  is  not  advisable  to  make  any  application  to 
the  cervical  canal  during  the  acute  stage,  because  of  the 
danger  of  carrying  infection  to  the  uterine  cavity.  The  treat- 
ment as  outlined  in  the  previous  section  (14)  of  this  chapter 
gives  good  results. 

2.  Chronic  stage  is  one  of  the  most  stubborn  conditions  in 
gynecology.  The  gonococci  have  penetrated  the  ducts  of  the 
cervical  glands,  a  mixed  infection  has  taken  place,  and  the 
irritation  of  this  infection  causes  a  profuse  stringy  mucopuru- 
lent discharge. 

Symptoms. — (i)  The  patient's  chief  complaint  is  a  profuse, 
annoying  leukorrhea;  (2)  the  cervix  is  eroded;  (3)  the  cervix 
and  vaginal  vaults  are  covered  with  stringy  cloudy  mucopus; 
(4)  gonococci  may  be  found  with  some  difl&culty. 


314  GONORRHEA 

Treatment: — In  addition  to  the  treatment  described  in  sec- 
tion 14,  the  following  will  be  found  useful:     . 

(i)  Instillation  into  the  cervix,  T\dth  an  instillating  syringe, 
of  25  per  cent,  argyrol,  10  per  cent,  silvol;  50  per  cent,  ichthyol 
all  made  up  in  ghxerin  (watery  solutions  run  out  at  once,  while 
the  thicker  glycerin  exudes  slowly  from  the  cervical  canal), 
injections  are  given  every  other  day.  (2)  Electrolysis  with  a 
copper  electrode.  The  electrode  is  placed  in  the  cervix,  the 
positive  pole  attached  to  it,  and  a  galvanic  current  of  25  to 
40  milliamperes  allowed  to  flow  for  thirty  minutes  every  other 
day.  (3)  Amputation  of  the  cervix,  if  there  is  hypertrophy  and 
severe  erosion. 

Douches  are  used  for  cleanliness  only,  as  they  do  not  reach 
the  seat  of  the  infection. 

Prognosis. — The  condition  is  exceedingly  stubborn.  Treat- 
ment must  be  continued  until  the  cervical  mucus  is  clear,  and 
then  interrupted  to  watch  results.     Relapses  are  common. 

16.  Gonorrheal  Endometritis. — The  endometrium  is  fairly 
immune  to  a  permanent  gonorrheal  infection.  Invasion  from 
the  cervix  takes  place  usually  just  before  or  just  after  a  men- 
strual period.  The  endometrium  seems  to  serve  chiefly  as 
a  bridge  for  the  gonococci  to  reach  the  tubes,  and  not  as.  a 
permanent  home.  The  chief  source  of  discharge  is  the  cervix 
and  not  the  corporeal  endometrium.  For  these  reasons  gonor- 
rheal endometritis  is  not  a  disease  for  local  or  general  treatment 
except  as  an  incident  in  the  treatment  of  complicating 
pyosalpinx. 

Curetment  can  do  only  harm  and  is  absolutely  contra- 
indicated  except  in  connection  with  laparotomies  for  remov^al 
of  the  tubes  for  salpingitis,  when  there  is  usually  a  chronic 
endometritis  existing  with  the  tubal  disease.  Curetment 
of  a  case  where  the  tubes  are  not  diseased,  is  a  sure  way  of 
producing  an  acute  pyosalpinx  or  pelvic  abscess. 

Many  cases  of  pelvic  inflammation  are  associated  with 
menorrhagia  or  metrorrhagia,  but  this  is  not  an  indication  for 
curetment,  unless  at  the  same  time  the  tubes  are  removed. 


VACCINES    AND    SERUM  315 

In  operation  for  gonorrheal  pyosalpinx,  a  preliminary  curet- 
ment  should  always  be  done,  followed  by  cauterization  of  the 
endometrium  with  tincture  of  iodin  (7  per  cent.)  and  pure 
carbolic  acid  equal  parts,  and  the  vagina  then  wiped  out  with 
95  per  cent,  alcohol  (but  not  the  uterus). 

17.  Gonorrheal  salpingitis  and  pelvic  abscess  have  been 
described  in  Chapter  VIII. 

18.  Complications  of  gonorrhea  are  (i)  Abscess  of  Skene's 
glands  (Chapter  IV);  (2)  abscess  of  Bartholin's  glands 
(Chapter  IV);  (3)  condylomata  acuminata  (venereal  warts) 
(Chapter  IV);  (4)  arthritis;  (5)  general  septicemia;  (6)  peri- 
tonitis; (7)  pyelitis;  (8)  ophthalmia. 

Arthritis  is  rare  in  women,  but  may  appear  in  any  case.  It 
is  much  more  common  after  labor  or  miscarriage  than  at  other 
times.  The  joints  most  commonly  affected  are  the  ankle, 
elbow,  wrist,  knee,  in  that  order,  and  then  the  small  joints. 

Suppuration  is  not  the  rule,  but  the  risk  of  ankylosis  is 
about  20  per  cent. 

Treatment. — (i)  Immobilization  of  the  part;  (2)  application 
of  saturated  magnesium  sulphate  solution  or  equal  parts  of 
dilute  leadwater  and  alcohol;  (3)  strapping  after  the  acute 
stage  is  past;  (4)  massive  doses  of  vaccines. 

Peritonitis  is  usually  the  result  of  general  gonorrheal  septi- 
cemia, and,  if  a  diagnosis  of  its  nature  can  be  made,  is  best 
treated  conservatively,  as  the  prognosis  is  favorable. 

Ophthalmia  is  a  serious  risk  to  any  patient  or  attendant,  from 
hand  infection.  All  persons  should  be  warned  of  the  danger 
and  cleanliness  enforced. 

19.  Vaccines  and  Serum.  — Gonorrhea  is  as  a  rule  not  much 
influenced  by  vaccine  or  serum,  with  two  important  exceptions : 
(i)  Vulvo-vaginitis  in  children;  (2)  gonorrheal  arthritis.  The 
serum  is  prepared  from  the  blood  of  sheep  who  have  been 
treated  with  virulent  culture  of  gonococci. 

Dosage  is  2  c.c.  given  daily  in  the  thigh,  for  five  successive 
days.  There  is  considerable  local  reaction,  due  to  the  toxicity 
of  the  serum,  and  results  have  not  been  encouraging. 


3l6  GONORRHEA 

Vaccines  need  not  be  autogenous.  The  commercial  prepa- 
rations of  mixed  strains  are  satisfactory.  The  opsonic 
index  should  be  taken,  but  even  this  is  not  essential. 

Dosage  at  first  ten  to  twenty  millions,  given  five  days  between 
doses,  and  increasing  by  ten  or  twenty  millions  to  each  dose. 
An  average  number  of  six  injections  will  be  required.  Local 
and  general  reactions  are  often  seen,  but  usually  mild  and 
of  short  duration.  Anaphylaxis  is  not  to  be  feared,  except 
after  small  doses-  with  long  intervals.  Large  doses  are  safer 
than  small  ones,  and  there  is  more  danger  of  anaphylaxis  in 
chronic  than  in  acute  cases. 


CHAPTER  XVI 

NORMAL  MENSTRUATION  AND  ITS 
ABNORMALITIES 

Menstruation  appears  usually  about  the  fourteenth  year,  and 
continues  until  the  forty-fifth.  It  may  appear  as  early  as  the 
eleventh  year  or  as  late  as  the  sixteenth,  and  still  be  within 
normal  limits.  When  first  established,  periods  are  apt  to  be 
irregular,  but  when  fully  instituted,  the  average  interval  is 
twenty-eight  days.  The  interval  next  in  frequency  is  twenty- 
three  days. 

Duration  of  the  flow  is  three  or  four  days. 

Amount  of  flowis,  on  the  average,  50  grams  (3  ounces).  It  is 
less  in  single  women,  and  somewhat  more  in  women  who  have 
had  children.  It  is  usually  measured  by  the  number  of  napkins 
used;  a  flow  requiring,  during  its  height,  more  than  three 
napkins  a  day,  can  be  regarded  as  excessive. 

Character  of  Menstrual  Blood.- — It  is  more  watery  and' 
darker  than  normal  blood.     It  is  mixed  with  epithelium  and 
mucus  from  the  cervical  and  uterine  glands.     It  does  not  clot, 
due  to  the  alkaline  cervical  mucus  with  which  it  is  mixed,  or 
possibly  to  a  local  influence  of  ovarian  secretion. 

Factors  Influencing  Menstruation. — (i)  Climate,  though  to 
a  less  extent  than  formerly  supposed.  It  affects  the  frequency 
of  the  periods  rather  than  the  age  of  puberty;  the  inter- 
menstrual interval  being  longer  in  colder  regions;  (2)  changes 
of  climate,  causing  amenorrhea  or  menorrhagia  (in  the  tropics) ; 
(3)  social  conditions;  the  poorer  classes  beginning  late  and 
ending  earlier  than  the  well-to-do;  (4)  city  dwellers  come  to 
puberty  slightly  earlier  than  those  who  live  in  the  country; 
(5)  nulliparous  women  and  virgins  reach  the  menopause  earlier 

317 


3l8  NORMAL   MENSTRUATION 


Fig.   i37.^Premenstrual  Endometrium.     (Graves.) 

Low  power.  At  the  bottom  is  the  muscle  of  the  uterine  wall,  sharply 
demarcated  from  the  endometrium.  The  glands  in  the  deepest  part  of 
the  endometrium  are  small,  their  epithelial  cells  low,  for  this  part  of  the 
glands  remains  inactive.  The  stroma  cells  are  small  and  lie  close  together. 
At  the  middle  of  the  endometrium  the  glands  are  dilated,  the  epithelium  > 
wavy,  and  the  epithelial  cells  swollen  and  actively  secreting  mucus. 
The  stroma  cells  are  larger  and  lie  further  apart.  On  the  right  the 
-dilatation  of  the  blood-vessels  is  well  shown.  Near  the  top  the  glands 
have  the  same  characteristic  as  at  the  middle,  but  there  is  more  edema  of 
the  stroma.     Throughout  there  is  a  slight  infiltration  with  round  cells. 


ENDOMETRIUM   DURING   MENSTRUATION 


319 


than  those  who  have  had  children;  (6)  those  who  reach  puberty 
early  tend  to  menstruate  profusely  and  reach  the  menopause 
late. 

The  uterus  during  menstruation  is  larger,  softer,  more  com- 
pressible, and  shows  marked  congestion,  as  do  all  the  pelvic 
organs,  both  internal  and  external  genitalia. 


Fig.  138. — Endometrium  at  Beginning  of  Menstruation.     {Graves.) 

The  glands,  except  for  the  one  seen  in  the  center,  have  collapsed,  having 
discharged  the  material  which  was  secreted  during  the  premenstrual  stage. 
The  blood-vessels  have  been  eroded  by  the  ferment  contained  in  the 
secretion,  allowing  the  blood  to  exude  into  the  tissue  and  on  the  sur- 
face of  the  endometrium.  The  surface  epithelium  in  this  section  is  still 
intact. 


Precocious  menstruation,  seen  in  very  young  subjects,  two 
to  four  years  old,  usually  associated  with  abnormally  developed 
breasts  and  genitalia,  and  is  due  to  abnormalities  in  the  glands 
of  internal  secretion,  especially  the  pineal. 

The    Endometrium    during    Menstruation. — The    uterine 


320  NORMAL   MENSTRUATION 

mucosa  passes  each  month  through  three  phases  or  cycles: 
(i)  Premenstrual  congestion;  (2)  period  of  menstruation;  (3) 
postmenstrual  involution. 

I.  Premenstrual  congestion  begins  about  ten  days  before  the 
period.     The  mucosa  is  thickened  (6-7  mm.  in  depth).     The 


Pig.  139. — Postmenstrual  Endometrium.     {Graves.) 

Low  power.  The  surface  epithelium  is  regenerated.  The  glands  are 
still  dilated,  but  the  epithelium  is  low,  the  nuclei  of  the  cells  small  and 
lying  at  the  bases.  There  is  some  edema  of  the  stroma  near  the  top,  but 
the  cells  are  smaller,  the  blood-vessels  collapsed.  There  is  a  slight 
infiltration  with  round  cells  and  blood-corpuscles. 

cells  are  swollen  and  pale — like  decidua  cells.  The  endome- 
trium presents  two  layers — the  deep  spongy  layer  containing 
the  glands  and  the  superficial  compact  layer,  formed  of  swollen 
stroma  cells.  The  surface  is  irregular  and  furrowed,  and  the 
blood-vessels  dilated  and  tortuous. 


ENDOMETRIUM   DURING   MENSTRUATION 


321 


2.  Stage  of  Menstruation. — The  blood  escapes  partly  by  ac- 
tual rupture  of  the  vessels,  but  largely  by  diapedesis,  and  forms 
subepithehal  hematomata.  Uterine  contractions  force  the 
blood  through  the  mucosa  into  the  uterine  cavity,  partly 
through  the  interstices  of  the  cells  of  the  gland  lumina  and 
partly  by  actual  desquamation  of  the  surface  epithelium. 

3.  Postmenstrual  involution  or  stage  of  quiescence.  After 
the  cessation  of  bleeding,  the  mucosa  shrinks  to  its  previous 
thickness  of  2-3  mm.     The  blood-vessels  contract,   the  ex- 


MenstruattOTi 


Pig.   140. — Goodman-von   Ott  wave.      (Graves.) 


travasated  blood  is  absorbed.  The  broken  epithelial  layers 
replaced  by  new  cells.  The  glands  resume  their  narrow  and 
straight  form.  This  stage  lasts  about  fourteen  days,  and  the 
cycle  then  begins  anew.  During  the  cycle  of  congestion  there 
is  a  glycogen  production  from  the  mucosa,  reaching  its  height 
during  menstruation  and  disappearing  during  the  stage  of 
quiescence. 

The  Goodman-von  Ott  curve  or  wave  is  a  diagrammatic 
curve  representing  the  energy  of  all  functions  of  the  female 
organism,  with  reference  to  the  menstrual  period.     This  energy 


322  NORMAL   MENSTRUATION 

is  at  its  height  three  days  before  the  flow,  and  at  its  lowest 
at  the  end  of  the  period. 

The  molimina  of  menstruation  are  the  visible  e\ddences  of 
the  process,  affecting  not  only  the  genitalia  but  the  entire 
organism.  The  breasts  are  often  engorged  and  frequently 
secrete  colostrum;  there  is  usually  a  marked  physical  and 
mental  depression;  the  nervous  system  is  particularly  unstable; 
mostly  manifested  by  irritability,  neuroses  and  headache; 
pelvic  discomfort  is  the  rule,  varjdng  from  a  sense  of  pressure 
to  severe  cramp-Hke  pains;  vasomotor  disturbances  are 
common — nose-bleed,  edema  of  the  throat  and  larynx,  hot 
flushes,  etc.;  skin  eruptions  often  appear  only  at  this  time. 
The  sexual  impulse  is  increased  just  before  or  after  the  period, 
and  decreased  or  absent  during  the  flow. 

Pain  midway  between  periods  is  most  commonly  due  to  in- 
tramural fibroids,  but  often  occurs  without  demonstrable  cause. 

Relation  of  Menstruation  to  Ovulation. — The  two  processes 
can  and  often  do  occur  independently.  In  a  strictly  normal 
case,  o\nilation  should  precede  'menstruation  by  two  or  three 
days,  but  the  occurrence  of  pregnancy  during  the  amenorrhea 
of  lactation  is  sufiicient  proof  that  there  is  no  absolutely  fixed 
relationship. 

ABNORMALITIES  OF  MENSTRUATION 
L  Amenorrhea  (Absence  of  Flow) 

Causes. — ^I.  Anatomical. — (i)  lU  development;  (2)  atresia 
of  hymen,  vagina  or  cervix;  (3)  congenital  absence  of  uterus. 

II.  Constitutional. — (i)  Chronic  systemic  disease  hke  tuber- 
culosis, diabetes,  nephritis ;  (2)  change  of  climate;  (3)  neurotic, 
as  in  cases  of  pseudocyesis;  (4)  disturbances  of  glands  of  in- 
ternal secretion. 

III.  Physiological. — (i)    Before    puberty;    (2)    pregnancy; 

(3)  lactation;  (4)  menopause. 

IV.  Pathological. — (i)  Inflammation  destroying  the  ovary; 
(2)  operations  removing  ovaries  or  uterus;  (3)  acquired  atresia; 

(4)  pelvic  tumors  (most  commonly  ovarian  cysts). 


ABNORMALITIES    OF   MENSTRUATION  323 

Under  "functional  amenorrhea"  are  classed  cases  not  due  to 
any  definite  pathological  cause,  such  as  fear  or  anger,  climatic 
changes,  obesity,  exposure  to  cold,  etc. 

Amenorrhea  of  Youth. — It  is  common  for  menstruation  to  be 
very  irregular  or  scanty  for  one  or  two  years  from  its  first 
appearance.  Periods  of  three  to  six  months  pass  without  a 
flow.  If  the  patient  retains  good  health,  no  treatment  is  re- 
quired. In  nervous,  anemic,  ill-developed  girls,  great  benefit 
can  be  derived  from  hypodermic  administration  of  corpus 
luteum  or  whole  ovarian  extract.  Dosage  is  one  ampule 
(representing  20  mg.  of  the  dried  substance),  given  intra- 
muscularly daily  in  series  of  24  doses.  This  is  much  better  and 
more  reHable  than  mouth  administration  of  tablets  or  capsules 
of  ovarian  substance  (5  grains  four  times  daily). 

Treatment  of  amenorrhea  depends  largely  on  the  cause,  if 
one  can  be  found. 

Absence  of  flow  due  to  atresia  is  not  true  amenorrhea,  as  the 
flow  occurs,  but  is  dammed  back.  The  treatment  of  these 
cases  is  described  in  Chapter  III.  Ill  development  can  be 
helped  by  (i)  hypodermic  injections  of  i  mil.  (representing  20 
mg.  of  dried  gland)  of  corpus  luteum  or  whole  ovarian  extract, 
daily  in  series  of  twenty-four  doses,  with  an  interval  of  several 
weeks  between  series;  (2)  electrical  stimulation  of  the  uterus, 
the  negative  pole  in  the  uterus,  using  galvanic,  slow  faradic 
and  sinusoidal  currents,  three  times  weekly  for  forty-five  min- 
utes at  each  treatment.  3.  In  congenital  absence  of  the  uterus, 
nothing  can  be  done.  4.  Amenorrhea  due  to  chronic  systemic 
diseases  will  yield  as  a  rule  to  treatment  of  the  disease  at 
fault.  Anemia  requires  prolonged  administration  of  iron, 
arsenic  and  strychnin,  a  very  satisfactory  capsule  being  the 
following : 

I^       Acid,    arsenios gr.   J-s 

Strychnin    sulph gr.  i 

Ferri  pyrophosphat gr.   150 

M.  Ft.   caps.  No.  30 

Sig.    One  three  times  daily. 


324  NORMAL   MENSTRUATION 

5.  None  of  the  physiological  causes  require  any  treatment 
but  it  is  worth  remembering  that  prolonged  nursing  may  give 
rise  to  such  a  degree  of  lactation  atrophy  as  to  cause  permanent 
amenorrhea.  These  patients  are  treated  hke  those  with  ill 
development.  6.  The  pathological  causes  destroying  the 
ovary  or  uterus  are  irremediable.  The  only  chance  is  implan- 
tation of  sections  of  ovary,  with  very  small  chance  of  success. 
Corpus  luteum  extract  will  banish  the  disagreeable  symptoms 
of  the  menopause,  but  will  not  cause  the  flow  to  return.  The 
commonest  pelvic  tumor  to  cause  amenorrhea  is  the  large 
ovarian  cyst.  After  removal  of  the  cyst,  unless  bilateral, 
regular  menstruation  will  return.  7.  Functional  amenorrhea 
due  to  severe  anger,  fright,  nervous  shock,  fear  of  pregnancy 
requires  no  treatment.  That  due  to  change  of  occupation 
or  climate  (as  in  domestic  servants)  requires  good  food,  hy- 
giene, regular  rest  and  exercise,  and  prolonged  courses  of  iron, 
arsenic  and  strychnin.  That  due  to  cold  is  described  under 
the  heading  "Acute  Suppression." 

Emmenagogues. — Drugs  to  produce  menstruation  are  of 
little  value.  Those  most  used  are:  (i)  oxahc  acid  gr.  3^^  four 
times  daily,  given  in  2  drams  syrup  of  lemon;  (2)  dioxid  of 
manganese  gr.  2  four  times  daily;  (3)  permanganate  of  potas- 
sium gr.  2  four  times  daily;  (4)  aspirin  gr.  5  four  times  a  day. 
They  all  tend  to  upset  the  stomach  and  are  not  recommended. 

The  best  emmenagogue  is  the  electrical  current,  galvanic, 
negative  pole  to  the  uterine  electrode. 

Chlorosis  is  a  disease  occurring  at  puberty,  having  a  tendency 
to  recur  at  the  menopause,  characterized  by  a  nearly  normal 
red  count  and  a  low  hemoglobin  content.  The  coagulability 
of  the  blood  is  increased. 

Symptoms. — (i)  The  patient  is  pale,  with  a  pecuhar  greenish 
tint,  and  usually  underdeveloped;  (2)  she  complains  of  amenor- 
rhea, or  very  scanty  flow  associated  with  dysmenorrhea; 
(3)  the  blood  count  is  as  described  above;  (4)  there  is  no  leu- 
kocytosis; (5)  marked  dyspepsia  due  to  hyperacidity. 

Treatment. — (i)  Fresh  air,  open  air  exercise  and  nourishing 


ABNORMALITIES   OF   MENSTRUATION,  325 

food;  (2)  alkalis  (sod.  bicarbonate)  for  the  hyperacidity;  (3) 
iron,  in  the  form  of  Blaud's  pills  (three  to  nine  a  day)  is  the  most 
valuable  single  drug;  (4)  mild  saline  laxatives;  (5)  very  severe 
cases  require  complete  rest  in  bed;  those  with  a  hemoglobin 
percentage  of  below  thirty. 

Prognosis  is  good,  though  up  to  the  twenty-fifth  year  relapses 
are  common. 

Acute  suppression  of  menses  is  most  often  due  to  cold.  It 
is  associated  with  severe,  often  agonizing,  pelvic  pain,  simu- 
lating peritonitis,  due  to  severe  pelvic  congestion. 

Treatment. — (i)  Be  sure  the  suppression  is  not  due  to  normal 
or  extra-uterine  pregnancy;  (2)  rest  in  bed;  (3)  hot  flaxseed 
poultice  or  hot  water  bag  to  lower  abdomen  constantly;  (4) 
hot  vaginal  douches  (i  gallon  at  i2o°F.,  run  in  slowly  with 
patient  lying  down)  of  sterile  water  four  times  daily.  In 
young  girls,  hot  enemata  are  substituted;  (5)  sahne  purge 
(best  flat  magnesium  citrate,  12  ounces);  (6)  for  the  reUef 
of  pain  give  antipyrin  gr.  2,  ammonium  carbonate  gr.  3 
every  three  hours;  salol  and  phenacetin  each  gr.  23^^  every 
three  hours ;  tincture  of  aconite  one  drop  every  half  hour  until 
the  sense  of  pelvic  congestion  is  reHeved;  codein  sulphate  gr. 
3^^  hypodermically;  heroin  gr.  K2  or  morphin  gr.  }yi 
hypodermically  only  as  a  last  resort. 

Scanty  menstruation  is  due  to  many  of  the  same  causes  that 
lead  to  amenorrhea  and  the  treatment  is  the  same. 

II,  Dysmenorrhea  or  Painful  Menstruation 

Causes. — (i)  Mechanical  obstruction  due  to  congenital  or 
acquired  stenosis  of  the  internal  os;  (2)  malposition  of  the  uterus 
(anteflexion,  retroflexion  and  retroversion,  in  that  order  of 
frequency) ;  (3)  ill  development  of  the  uterus,  usually  associated 
with  stenosis;  (4)  pelvic  congestion,  due  most  often  to  uterine 
displacement;  (5)  pelvic  inflammation,  of  tubes  and  ovaries; 
(6)  postoperative,  due  to  Hgatures  or  adhesions;  (7)  cirrhosis 
of  the  ovaries. 


326  NORMAL   MENSTRUATION 

Dysmenorrhea  is  not  a  disease,  but  a  symptom  of  many 
pelvic  diseases. 

Sjnnptoms. — (i)  Pain,  cramp-like  and  often  severe,  either 
just  before  or  during  the  first  day  of  the  period;  (2)  incapacity 
of  varying  degree;  (3)  the  pain  extends  down  the  back  of  the 
legs,  and  is  often  associated  with  a  sense  of  prolapse;  (4) 
symptoms  usually  appear  early  in  menstrual  life  and  tend  to 
grow  worse;  (5)  headache,  general  malaise  and  vomiting  are 
common;  (6)  the  intermenstrual  interval  is  usually  free  from 
pain. 

Intermenstrual  pain  ("  mittelschmerz  ")  is  due  usually  to  an 
intramural  fibroid,  though  it  not  infrequently  occurs  in  patients 
in  whom  no  cause  can  be  found. 

Treatment  of  dysmenorrhea  depends  upon  the  cause. 

Medical  treatment  is  unsatisfactory.  A  great  number  of 
drugs  have  been  recommended,  but  all  fail  frequently.  The 
best  are:  Antipyrin  gr.  2,  ammonium  carbonate  gr.  3  every 
four  hours;  (2)  aspirin  gr.  5  four  times  a  day;  (3)  sodium 
bromid,  gr.  20  four  times  daily;  (4)  alcohol  (whiskey,  or 
brandy  oz.  ^-^  in  4  ounces  very  hot  water);  (5)^  atropin, 
grain  Moo  by  mouth  three  times  daily,  for  two  days  before  and 
the  first  two  days  of  the  period;  (6)  soluble  ovarian  extract  or 
corpus luteum extract  imil  (20 mg.)  hypodermically  twice  daily. 
(7)  morphin,  heroin  and  other  habit-forming  drugs  are  to  be 
avoided.  Their  use  in  women  with  dysmenorrhea  is  one  of  the 
commonest  causes  of  drug  habit. 

Nasal  Treatment. — In  patients  who  have  any  nasal  abnor- 
mality (deflected  septa,  hypertrophy  of  the  middle  turbinates, 
etc.)  and  those  in  whom  the  flow  is  preceded  by  headache  and 
nausea,  cocainization  of  the  "genital  spots"  in  the  nose  (the 
tuberculum  septi  and  middle  turbinate)  has  given  good  results. 
At  present  the  galvanocautery  or  trichloracetic  acid  is  used 
with  more  lasting  effect,  and  if  good  results  are  obtained  at  the 
first  trial,  the  procedure  is  repeated  between  the  periods. 
After  two  or  three  treatments,  the  relief  is  said  in  many  cases 
to  be  permanent. 


ABNORMALITIES    OF    MENSTRUATION  327 

Operative  Treatment. — (i)  In  cases  of  stenosis,  forcible 
dilatation,  followed  by  either  Schatz's  metranoikter  or  the 
Wylie  drain  (preferably  the  former) ,  will  give  most  satisfactory 
results.  The  technic  is  described  in  Chapter  VII.  Dilatation 
alone,  without  some  means  of  keeping  the  canal  open  for  some 
time,  is  practically  useless. 

2.  Dudley's  operation  of  splitting  the  cervix  and  inserting 
stitches  so  as  to  eliminate  the  cervical  canal,  is  mutilating 
and  is  often  followed  by  a  troublesome  endocervicitis,  which 
may  require  repair  or  amputation  of  the  cervix. 

3.  In  cases  complicated  by  backward  displacement  of  the 
uterus,  the  displacement  must  be  corrected  by  pessary  or 
operation. 

4.  Cases  due  to  pelvic  inflammation  and  adhesions  require 
abdominal  section.. 

5.  Cases  due  to  ovarian  cirrhosis  (seen  in  elderly  nulliparae, 
the  pain  being  due  to  ovarian  congestion  causing  the  ovary 
to  swell  against  its  firm  shrunken  capsule)  require  abdominal 
section.  This  is  the  type  called  ovarian  neuralgia  and  is 
sometimes  seen  in  young  women. 

Marriage  and  Sterility. — Many  cases  of  essential  dysmenor- 
rhea are  sterile,  due  to  anteflexion  and  stenosis  or  ill  develop- 
ment. These  cases  are  helped  by  marriage,  and  if  they  should 
become  pregnant,  the  dysmenorrhea  is  permanently  cured  by 
the  dilatation  during  delivery. 

Membranous  dysmenorrhea  is  a  condition  characterized 
by  intense  pain  at.  the  menstrual  periods,  accompanied  by 
exfoliation  and  discharge  of  portions  of  the  uterine  mucosa 
varying  from  small  pieces  to  complete  casts  of  the  uterine 
cavity.  As  this  mucosa  is  the  menstrual  compact  layer,  its 
likeness  to  decidua  is  such  that  even  in  microscopic  section 
there  may  be  doubt  as  to  the  diagnosis. 

Cause  is  not  definitely  known.  It  is  ascribed  rather  vaguely 
to  an  abnormal  reaction  between  the  ovarian  secretion  and  the 
uterine  mucosa.  Some  cases  follow  abortion  and  in  these  there 
can  be  demonstrated  chronic  interstitial  endometritis. 


328  NORMAL   MENSTRUATION 

Symptoms  are  as  given  in  the  definition  of  the  disease. 

Prognosis  as  to  complete  cure  is  not  good,  and  treatment  is 
often  unsatisfactory. 

Treatment. — The  best  treatment  is  dilatation  and  curettage 
just  before  the  period,  during  the  stage  of  thickening  of  the 
mucosa,  followed  by  cauterization  of  the  endometrium  by  iodin 
(7  per  cent,  tincture)  or  carbolic  acid  or  steam  (atmokausis, 
see  section  on  metrorrhagia).  Repeated  operations  are  re- 
quired, as  a  rule. 

Nervous  symptoms  vary  from  nervous  dread  of  the  pain  of 
the  approaching  period  up  to  epileptiform  convulsions  (hys- 
tero-epilepsy).  They  are  treated  by  removing  their  primary 
cause  (the  pain),  good  hygiene  and  diet,  regular  exercise  and 
occasionally  mental  therapy  and  suggestion.  In  hystero- 
epilepsy,  oophorectomy  is  not  indicated,  as  it  does  no  good. 

in.  Menorrhagia  (Excessive  Menstrual  Flow) 

By  this  term  is  meant  (i)  an  increased  flow  at  the  periods; 
(2)  increased  frequency  of  the  periods  (the  interval  being 
free  from'  any  bleeding);  (3)  prolongation  of  the  menstrual 
period. 

Amount  of  Flow. — If  the  period  requires  more  than  three  or 
four  napkins  daily  (a  total  of  twelve  to  sixteen),  or  requires 
that  the  napkins  be  worn  double,  or  if  there  are  clots  of  con- 
siderable size,  the  flow  is  abnormal. 

Causes. — (i)  Displacements  of  the  uterus;  (2)  pelvic  con- 
gestion from  any  cause  especially  with  subinvolution  of  the 
uterus;  (3)  fibroid  tumors;  (4)  chronic  endometritis;  (5) 
chronic  pelvic  inflammation;  (6)  excessive  or  abnormal  coitus; 
(7)  valvular  heart  disease;  (8)  high  blood-pressure;  (9)  polyps 
(mucous  or  fibroid);  (10)  menorrhagia  of  youth;  (11)  approach- 
ing menopause  (always  suspicious);  (12)  ''functional" — in 
which  no  definite  cause  can  be  found. 

Treatment. — Menorrhagia  is  a  symptom  only,  and  if  the 
causative  conditions  be  found  and  removed,  the  menstrual 
flow  returns  to  normal.     In  cases  of  valvular  heart  disease  or 


ABNORMALITIES    OF    MENSTRUATION  329 

abnormally  high  blood-pressure,  the  bleeding  may  be  beneficial, 
and  when  checked,  the  patient  is  uncomfortable. 

For  checking  the  bleeding  at  the  time  of  the  period,  the 
following  are  indicated:  (i)  Rest  in  bed;  (2)  laxatives  sufficient 
to  secure  one  or  two  good  movements  a  day;  (3)  sedatives 
(strontium  bromid  gr.  15  every  three  hours)  if  the  patient  is 
nervous  and  restless;  (4)  styptics;  ergot  gr.  i,  strychnin  sulphat. 
gr.  3^^o  in  capsule  four  times  daily;  or  fluid  extract  of  ergot  20 
drops  four  times  daily;  or  stypticin  gr.  i,  four  times  daily;  or 
cotarnin  hydrochlorid  gr.  i  four  times  daily;  or  styptol  gr. 
%  five  times  a  day;  or  hydrastinin  gr.  ]y^  four  times  daily. 
All  these  alkaloids  are  efiicient  but  very  expensive;  (4)  if  dys- 
menorrhea is  also  present  (a  common  complication),  and  is 
severe,  3^^  grain  opium  suppository  is  given  twice  daily,  but 
the  patient  is  not  told  the  nature  of  the  drug;  (5)  calcium  lac- 
tate or  chlorid  gr.  20  four  times  daily,  to  increase  the  coagu- 
latibility  of  the  blood;  (6)  in  severe  bleeding,  vaginal  tampons 
of  sterile  gauze  for  twenty-four  hours  may  be  needed. 

Animal  extracts  (pituitrin;  mammary  extract;  suprarenal 
extract)  have  given  poor  results  in  menstrual  excess  in  the 
adult.  The  most  reliable  is  pituitrin  ^^  mil  hypodermically 
twice  daily.  A  point  never  to  he  forgotten  is  that  a  sudden  ex- 
cessive menstrual  How  may  be  a  very  early  abortion;  the  patient 
often  not  knowing  she  is  pregnant. 

Menorrhagia  of  Youth.^ — In  young  girls,  excessive  men- 
strual flow  is  not  uncommon.  The  loss  of  blood  may  be  very 
severe  and  alarming,  and  has  been  fatal.  The  severe  cases  are 
probably  hemophilic  in  origin.  Some  of  the  less  severe  cases 
are  due  to  hypertrophic  glandular  endometritis,  but  in  many 
no  cause  at  all  can  be  found.  The  cause  is  supposed  to  lie  in 
loss  of  balance  of  the  internal  secretory  glands,  particularly  the 
thyroid,  but  this  has  not  yet  been  proven. 

Treatment  should  be  as  conservative  as  possible. 

(i)  Pituitrin  3^^  mil  hypodermically  daily  for  eight  or  ten 
doses,  though  three  or  four  are  usually  enough.  This  is  the 
most  valuable  single  drug;  (2)  calcium  lactate  gr.  20  four  times 


33©  NORMAL   MENSTRUATION 

a  day,  between  the  periods;  (3)  th)^roid  extract  5  grains  four 
times  daily,  between  the  periods.  This  routine  treatment  is 
ordinarily  all  that  is  required. 

Severe  cases:  (i)  Normal  horse  serum,  50  c.c.  subcutaneously 
and  repeated  daily  for  three  or  four  doses;  (2)  transfusion, 
preferably  from  one  of  the  parents,  250-500  c.c.  of  blood;  (3) 
dilatation  and  curettage  of  value  only  in  the  cases  of  glandular 
endometritis;  (4)  atmokausis  (see  treatment  of  metror- 
rhagia) ;  to  be  avoided  if  possible ;  (5)  a;-ray  will  stop  nearly 
all  cases,  but  is  to  be  avoided  except  as  a  last  resort,  because 
of  the  damage  done  to  the  ripening  ovarian  follicles,  and  the 
danger  of  permanent  menopause;  (6)  radium  treatment  is 
difficult  of  application,  except  under  anesthesia.  It  is  efficient 
but  open  to  the  same  objections  as  the  .v-ray;  (7)  only  as  a 
last  resort,  and  very  rarely  if  ever  necessary,  hysterectomy. 

IV.  Metrorrhagia  (Irregular  Bleeding,  Irrespective  of 

Menses) 

All  metrorrhagia  is  pathologic,  and  should  be  regarded  as 
serious,  especially  as  the  patient  nears  the  age  of  the  meno- 
pause. The  hemorrhages  of  pregnancy  are  included  under 
this  head,  but  their  discussion  belongs  properly  in  works  on 
obstetrics. 

Causes. — (i)  Incomplete  abortion;  (2)  extra-uterine  preg- 
nancy; (3)  laceration  and  erosion  of  cervix;  (4)  retroversion  of 
uterus;  (5)  chronic  endometritis;  (6)  fibroid  or  mucous  polyps; 
(7)  fibroid  tumors;  (8)  ovarian  cysts  (though  amenorrhea  is 
commoner);  (9)  cancer  of  the  uterus;  (10)  pyosalpinx;  (11) 
valvular  heart  disease;  (12)  high  blood-pressure;  (13)  any 
cause  of  acute  or  chronic  pelvic  congestion;  (14)  myopathic 
uterus  (fibroid  degeneration  of  the  muscular  wall);  (15) 
infectious  diseases,  notably  malaria. 

Diagnosis  of  the  Source. — (i)  Inspection  of  the  cervix 
through  a  bivalve  speculum.  In  this  way  erosion,  laceration, 
polyps,  or  cancer  can  be  seen;  (2)  bimanual  examination,  to 
detect  gross  pathological  lesions;  (3)  dilatation  and  curettage. 


ABNORMALITIES    OF    MENSTRUATION  33 1 

followed  always  by  exploration  of  the  uterine  cavity  with 
placental  forceps,  to  extract  if  possible  polyps  that  the  curet 
might  slip  over.  All  the  scrapings  should  always  be  examined 
microscopically;  (4)  uterine  endoscopy,  when  with  an  instru- 
ment like  a  urethroscope,  the  uterine  cavity  can,  after  proper 
dilatation  with  Hegar's  bougies,  be  inspected;  (5)  excision 
of  a  piece  of  the  cervix,  for  microscopic  examination  for  cancer; 
(6)  anterior  vaginal  hysterotomy,  when  a  submucous  fibroid 
is  suspected  with  reasonable  certainty;  (7)  in  all  cases, 
the  heart  should  be  examined  and  blood-pressure  taken. 

Treatment. — --Metrorrhagia,  like  menorrhagia,  is  a  symptom, 
and  the  cause  should  be  sought  and  removed.  In  sudden, 
severe  bleeding,  the  possibility  of  pregnancy  and  miscarriage 
must  never  be  forgotten. 

(i)  Bleeding  from  incomplete  abortion  is  quickly  and  easily 
controlled  by  cleaning  out  the  uterine  cavity  with  pla- 
cental forceps,  usually  without  anesthesia;  (2)  small  polyps 
in  the  cervical  canal  or  protruding  can  be  removed  with- 
out anesthesia;  (3)  bleeding  due  to  valvular  heart  dis- 
ease can  be  checked  or  at  least  diminished  by  oil  of 
erigeron,  tiex  four  times  daily  by  mouth;  (4)  in  high  blood- 
pressure,  the  bleeding  may  be  beneficial;  (5)  vaginal  douch- 
ing, tampons,  or  intra-uterine  application  are  of  little  use; 
(6)  cancer,  diagnosed  by  inspection  of  the  cervix  or  by  ex- 
ploratory curettage,  requires  prompt  panhysterectomy. 

In  Cases  without  Marked  Local  Lesion. — (i)  Styptics,  as  de- 
scribed under  menorrhagia;  (2)  electricity,  positive  pole  to 
uterine  electrode,  with  galvanic  current  of  40  milliamperes 
for  forty-five  minutes  three  times  weekly;  (3)  animal  extracts 
(pituitrin,  thyroid,  suprarenal  extract)  though  these  are  not 
efficient  as  a  rule,  except  in  very  young  patients;  (4)  a;-ray, 
except  in  degenerated  fibroid,  where  it  is  contraindicated; 
(5)  radium,  with  the  same  limitations  as  the  x-rsjy,  with  the 
additional  one  of  the  great  expense  of  the  supply  required. 
Radium  is  indicated  particularly  in  the  bleeding  due  to  the 
large,  firm,  myopathic  uterus;   (6)  dilatation  and  curettage, 


332  NORMAL   MENSTRUATION 

followed  by  atmokausis;  (7)  hysterectomy  when  other  means 
have  failed.  With  the  present  status  of  x-ray  and  radium 
treatment  and  atmokausis,  hysterectomy  is  rarely  needed 
except  in  cancer  and  degenerated  fibroids. 

Atmokausis  is  the  cauterization  of  the  endometrium  by  super- 
heated steam  at  a  temperature  of  ii5°C.  The  apparatus 
consists  of  a  boiler,  with  thermometer  and  safety  valve;  the 
outlet  tube  terminating  in  a  uterine  nozzle  controlled  by  a 
three-way  valve. 

Technic  of  Atmokausis. — (i)  The  patient  is  prepared  as  for 
any  vaginal  operation,  is  arranged  in  the  dorsal  position  and 
anesthetized. 

2.  The  cervix  is  dilated  to  one  inch  if  the  two-branched  di- 
lator, or  a  circumference  of  80  mm.  if  the  four-branched  Cleve- 
land dilator  is  used,  and  the  uterus  thoroughly  curetted, 
explored  with  placental  forceps,  and  washed  out  with  sterile 
water  through  an  intra-uterine  catheter. 

3.  Thirty-one  cubic  centimeters  of  hot  water  is  introduced 
into  the  boiler  of  the  atmokausis  apparatus  and  the  alcohol 
flame  is  started  under  the  boiler. 

4.  The  intra-uterine  nozzle  of  the  apparatus,  sterilized  by 
soaking  in  5  per  cent,  carbolic  acid  solution,  is  screwed  on  to 
the  handle,  all  the  joints  being  tightened,  and  as  soon  as  steam 
is  generated,  the  stop  cock  is  turned  slightly  to  test  the  tubes 
and  make  sure  the  lumen  is  free. 

5.  The  nozzle  is  then  inserted  into  the  uterine  cavity,  the 
point  being  near,  but  not  touching,  the  fundus. 

6.  When  the  thermometer  on  the  boiler  registers  ii5°C. 
the  steam  is  allowed  to  flow  through  the  nozzle  for  ten,  fifteen 
or  twenty  seconds,  or  as  long  as  the  individual  case  seems 
to  require. 

7.  The  uterus  is  then  washed  out  again,  and  the  patient 
returned  to  bed. 

8.  She  should  be  left  in  bed  ten  days,  and  during  her  conva- 
lescence may  require  intra-uterine  douches  if  a  foul  leukorrhea 
develops. 


ABNORMALITIES    OF   MENSTRUATION  :^^:^ 

g.  Repetition  is  rarely  needed. 

lo.  This  form  of  treatrrient  is  absolutely  contra-indicated  in 
cancer  or  degenerated  fibroids.  Its  field,  like  radium,  is  the 
myopathic  uterus. 

Zestokansis  is  the  same  except  that  the  uterine  nozzle  is 
closed,  and  the  steam  does  not  circulate  free  in  the  uterine 
cavity.     It  is  not  as  efiicient. 

Hysterectomy  may  be  supravaginal  (as  in  fibroids) ;  complete 
(either  abdominal  or  vaginal  panhysterectomy)  as  in  cancer; 
Supravaginal  extraperitoneal  (a  variation  of  vaginal  hysterec- 
tomy in  which  the  cervix  is  left);  partial  fundal,  to  diminish 
the  bleeding  endometrial  surface. 

V.  The  Menopause  (Climacteric,  Change  of  Life) 

This  is  reached  as  a  rule  at  about  forty-five  years  of  age.  In 
less  than  i  per  cent,  does  it  occur  before  thirty-five  or  after 
fifty-five.  It  is  reached  earlier  in  working  women  than  in  the 
leisure  class.  The  date  is  influenced  by  early  childbearing, 
fibroid  tumors,  chronic  pelvic  congestion,  climate,  occupation 
and  many  other  factors. 

Mechanism.-^The  periods  at  first  become  irregular,  then 
scanty  and  then  cease  entirely.  The  entire  process  is  prolonged 
over  two  or  three  years.  Rarely  the  menses  cease  abruptly 
and  never  reappear.  After  the  menopause  is  established,  all 
the  genital  organs,  external  and  internal,  show  a  process  of 
atrophy. 

Symptoms. — (i)  Menses  are  irregular,  then  scanty  and  then 
cease;  (2)  hot  flashes;  (3)  nervous  irritability,  dizziness  and 
tendency  to  mental  depression;  (4)  palpitation;  (5)  buzzing  in 
ears;  (6)  often  serious  psychoses;  (7)  often  marked  increase  in 
weight. 

Many  patients  pass  through  the  menopause  with  few  if  any 
disagreeable  symptoms,  but  the  first  three  mentioned  above 
occur  in  the  majority.  Just  before  the  climacteric  there  is 
usually  a  marked  increase  of  sexual  impulse,  which  disappears 
after  the  process  is  complete.     The  loss  of  ovarian  secretion  is 


334  NORMAL   MENSTRUATION 

thought  to  be  the  cause  of  the  menopause  and  its  disagreeable 
symptoms. 

The  surgical  menopause,  following  double  oophorectomy  or 
hysterectomy  is  more  severe  in  its  manifestations  than  the 
normal,  and  the  younger  the  patient  the  worse  and  more 
lasting  the  effects. 

Treatment. — Unless  the  disagreeable  symptoms  demand 
relief,  often  no  treatment  whatever  is  required.  In  patients 
who  require  treatment,  the  following  can  be  depended  upon: 
(i)  Mental  suggestion.  Reassure  the  patient  as  to  her  safety 
and  that  any  nervous  depression  is  merely  temporary;  (2) 
strontium  bromid,  15  grains  four  times  a  day,  with  periods 
of  remission  as  the  nervous  symptoms  are  controlled;  (3) 
hypodermic,  intramuscular  injections  of  soluble  extract  of 
corpus  luteum,  or  whole  ovarian  extract,  given  in  doses  of 
I  mil  (20  mg.)  daily  for  twenty-four  doses,  repeated  in  series 
of  twelve  doses  at  intervals  of  several  weeks.  This  is  the 
most  efficient  of  all  treatments,  and  rarely  are  more  than  two 
series  of  doses  required.  The  effect  is  cumulative.  The 
natural  menopause  requires  least;  the  surgical  menopause 
late  in  life  the  next  and  the  surgical  menopause  in  young 
women  the  largest  number  of  doses;  (4)  valerianates  are  not 
as  efficient  as  strontium  bromid.  When  used,  the  ehxir  of 
valerianate  of  ammonia,  in  teaspoonful  doses,  gives  the  most 
effect,  but  is  objectionable  as  a  rule  because  of  its  fearful 
smell. 

Bleeding  at  the  menopause  is  always  pathologic,  whether  it 
be  menorrhagia  or  metrorrhagia,  the  commonest  cause  being 
cancer,  fibroids  and  polj^s.  Any  abnormal  discharge,  whether 
blood,  leukorrhea  or  a  mixture  of  both,  should  be  carefully 
investigated  so  that  an  early  diagnosis  of  cancer  may  be 
established.  The  common  belief  that  an  excess  of  blood  at 
the  menopause  is  a  normal  feature  is  responsible  for  the  large 
number  of  cancers  that  reach  the  physician  too  late  for  relief. 

This  applies  with  equal  force  to  bleeding  or  abnormal  dis- 
charge after  the  menopause  is  established. 


ABNORMALITIES    OF    MENSTRUATION  335 

Vicarious  menstruation  is  the  discharge  of  blood  from  other 
body  canals,  at  the  normal  menstrual  time,  without  any  uter- 
ine flow.  It  is  commonest  from  the  nose,  but  may  occur  from 
any  mucous  surface,  such  as  stomach,  intestine,  lungs  or 
rectum.  Very  rarely  skin  areas  are  affected  showing  ecchy- 
moses.  The  vicarious  periods  are  likely  to  be  irregular  and 
may  alternate  with  periods  of  normal  flow. 

The  cause  is  unknown. 

Treatment. — Beyond  correction  of  any  pelvic  disease  or 
uterine  displacement;  iron  arsenic  and  strychnin  if  anemic; 
the  hypodermic  injections  of  corpus  luteum  or  whole  ovarian 
extract,  nothing  can  be  done. 


CHAPTER  XVII 
LEUKORRHEA  (THE  WHITES) 

Definition. — ^Leukorrhea  is  an  abnormal  discharge  from  the 
female  genital  tract,  consisting  as  a  rule  of  mucopus,  but  may 
be  mucus,  pus,  serum  or  combinations  of  these. 

Sources. — i.  Vulva:  Gonorrheal  infection  of  Skene's  ducts, 
the  urethra  and  Bartholin's  glands  account  for  most  cases.  It 
is  common  in  children,  and  in  the  aged,  in  the  latter  especially 
with  diabetes. 

2.  Vagina. — Vaginal  leukorrhea  is  not  common.  The  modi- 
fied skin  with  which  the  vagina  is  lined  resists  bacterial  infec- 
tion. Many  apparent  cases  of  vaginal  leukorrhea  originate  in 
Skene's  ducts,  urethra,  or  Bartholin's  glands.  Vaginal  dis- 
charge in  childhood  is  more  common  than  in  the  adult,  due  to 
the  susceptibility  of  the  vaginal  mucosa  to  gonorrheal  infection. 

In  the  adult,  the  commonest  causes  are:  (i)  Saprophytic  or 
fungus  infections;  (2)  senile  vaginitis  (when  the  discharge  is 
very  white,  due  to  degenerated  epithelium);  (3)  neglected  pes- 
saries, especially  soft  rubber  ones;  (4)  neglected  gonorrhea; 
(5)  carcinoma. 

3.  Cervix. — This  is  the  commonest  source  of  leukorrheal 
discharge.  The  normal  cervical  discharge  is  a  clear  mucus  and 
hardly  appreciable.  When  the  cervical  glands  are  infected  or 
irritated,  they  pour  out  large  quantities  of  mucus,  so  that  the 
patient  must  wear  napkins  for  protection. 

The  causes  of  cervical  leukorrhea  are:  (i)  Laceration  of  the 
cervix;  (2)  erosion;  (3)  eversion;  (4)  gonorrhea  (of  all  the  most 
stubborn  to  treat) ;  (5)  carcinoma;  (6)  non-bacterial  hyper- 
secretion of  the  cervical  glands  (most  often  in  virgins  and 
often  without  obvious  cause;  though  usually  in  neurotic  pa- 

336 


BACTERIOLOGY  337 

tients  and  those  with  displacement  of  the  uterus;  (7)  cervical 
polyps. 

4.  Uterus. — The  endometrium  is  not  prone  to  infection  and 
discharge.  Causes  of  uterine  leukorrhea  are:  (i)  Chronic 
interstitial  endometritis  (after  sepsis  or  gonorrhea);  (2)  chronic 
hyperplastic  glandular  endometritis  (though  bleeding  is  com- 
moner); (3)  senile  atrophic  endometritis;  (4)  incomplete  ab- 
ortion; (5)  sloughing  polyps;  (6)  cancer;  (7)  tubercular  endo- 
metritis. There  is  a  temporary  leukorrhea  just  preceding  or 
following  menstruation  and  due  to  hypersecretion  and  hyper- 
emia; it  is  so  common  as  to  be  physiologic. 

5.  Tubes. — Hydrosalpinx  (hydrops  tubse  profiuens)  and 
pyosalpinx  (pyosalpinx  profiuens)  sometimes  discharge  through 
the  uterine  cavity,  at  intervals;  but  other  than  this  the  tubes 
play  no  part  in  leukorrheal  discharge. 

Characteristics  of  Leukorrhea. — The  normal  vaginal  reac- 
tion is  acid;  in  leukorrhea  the  reaction  is  usually  neutral  or 
alkaline.  The  quantity  of  discharge  is  greatest  from  the  cervix, 
and  least  (except  in  vulvovaginitis  in  children)  from  the 
vagina.  The  consistence  varies  from  a  thin  watery  discharge 
(as  in  early  carcinoma  of  the  cervix)  to  a  profuse  creamy  ropy 
mucopus.  The  discharge  varies  in  color,  from  clear  mucus  to 
white,  yellow,  red,  green  (sloughing  fibroids)  to  dark  brown  or 
black.  As  a  rule  the  thinner  and  more  watery  the  discharge, 
the  more  persistent;  the  commonest  exception  to  this  is  chronic 
gonorrheal  endocervicitis.  It  is  often  blood-stained,  most 
commonly  in  cancer,  fibroid  polyps  or  senile  vaginitis. 

A  foul  discharge  is  rare  in  ordinary  leukorrhea;  it  is  the  rule 
in:  (i)  retained  products  of  conception;  (2)  cancer;  (3)  slough- 
ing polyps  or  fibroids;  (4)  neglected  pessaries. 

Bacteriology. — By  far  the  commonest  organism  is  the 
gonococcus,  especially  in  adults  who  have  not  borne  children. 
In  parous  women,  the  injuries  of  childbirth,  with  non-gonor- 
rheal  bacterial  invasion,  is  the  most  common  cause. 

Streptococci,  both  aerobic  and  anaerobic;  staphylococci, 
colon  bacilli,  gram-negative  anaerobes,  tubercle  bacilli,  and 


33^  LEUKORRHEA    (tHE    WHITEs) 

pneumococci  are  the  commonest  non-gonorrheal  organisms. 
All  these  are  of  low  virulence,  except  after  miscarriage  or  labor 
at  term. 

Diagnosis  as  to  source  is  made  as  follows:  i.  Inspection 
of  the  vulva  for  (i)  abscess  of  Skene's  glands;  (2)  urethritis; 
(3)  infection  of  Bartholin's  glands.  2.  Inspection  of  the  en- 
tire vaginal  wall,  through  a  skeleton  bivalve  speculum  made  of 
wire,  so  that  as  little  as  possible  of  the  vaginal  walls  is  hidden 
from  view.  3.  Inspection  of  the  cervix  through  the  same, 
or  a  solid  bladed  bivalve  speculum,  for  erosion  or  eversion, 
polyps  or  cancer.  4.  Bimanual  examination  of  the  uterus, 
tubes  and  ovaries,  to  detect  enlargement,  tumors,  fixation 
or  pelvic  iniiammation.  5.  If  no  cause  is  found  as  above,  and 
especially  if  the  patient  is  nearing  the  menopause,  exploratory 
dilatation  and  curettage,  with  microscopical  examination  of 
the  scrapings.  6.  Smears  are  always  taken  from  the  ureth- 
ral and  cervical  discharge. 

Treatment  is  best  considered  by  sources. 

General  Treatment. — The  patient's  general  health  should  be 
considered,  her  mode  of  life,  bowels  and  diet  regulated,  and 
iron,  arsenic  and  strychnin  given  when  she  is  anemic. 

1.  Vulvar  Leukorrhea. — The  vulvar  lesions  responsible  for 
the  discharge  are  nearly  always  gonorrheal  in  origin.  In- 
fected Bartholin's  glands  are  dissected  out;  infected  Skene's 
tubules  injected  with  nitrate  of  silver  8  per  cent.,  or  argyrol 
'25  per  cent,  or  silvol  5  per  cent,  by  a  hypodermic  syringe  with 
a  blunt  needle;  or  much  better  destroyed  by  the  electric  cau- 
tery needle  or  slit  up;  an  infected  urethra  is  treated  by  local 
applications.  Unless  these  lesions  are  removed,  other  local 
treatment  is  useless.  A  chronic  urethritis  is  usually  due  to 
infected  Skene's  glands. 

2.  Vaginal  Leukorrhea. — Vulvovaginitis  in  children  has  been 
considered  in  Chapter  XV  on  gonorrhea.  The  treatment  of 
neglected  pessaries,  tampons  or  other  foreign  bodies  is  ob- 
viously their  removal,  followed  by  douches  of  salt  solution 
twice  daily  until  the  erosions  caused  by  the  foreign  bodies  have 


TREATMENT  339 

healed  over.  If  the  patient  is  of  uncleanly  habits,  and  the 
discharge  results  from  saprophytic  or  fungus  infection,  douches 
twice  daily  or  mild  antiseptics  like  lysol  i  dram  to  2  pints,  or 
boric  acid  gr.  lo  to  oz.  i,  or  permanganate  of  potassium  i- 
3000  are  all  that  will  be  needed.  Cancer  is  treated  by  surgical 
means  if  possible;  if  far  advanced  by  :v-ray  or  radium. 

Senile  vaginitis,  associated  with  a  white  or  yellow,  often 
blood  streaked  discharge,  and  accompanied  by  intense  itching 
resists  all  ordinary  local  applications  or  douches.  In  these 
cases,  the  following  will  help  most  cases:  (i)  Swabbing  the 
entire  vaginal  mucosa,  with  7  per  cent,  tincture  of  iodin. 
Care  must  be  taken  not  to  let  any  excess  of  solution  run  down 
over  the  perineum  or  anus,  as  it  will  then  cause  intense  burning. 
This  application  must  be  repeated  several  times  at  intervals 
of  a  week,  as  the  patient's  condition  indicates.  (2)  Eight  per 
cent,  nitrate  of  silver  solution  (gr.  40  to  the  ounce)  used  in  the 
same  way.  (3)  Implantation  of  lactic  acid  bacilli,  as  follows: 
{a)  The  patient  is  arranged  in  the  dorsal  position,  the  vagina 
thoroughly  cleansed  with  salt  solution,  and  dried;  {b)  the 
cervix  is  exposed  with  a  bivalve  speculum;  (c)  a  lactic  acid 
tablet,  with  lactose  base,  is  moistened  with  sterile  water  (one 
or  two  drops  only)  and  inserted  in  the  posterior  vaginal  vault; 
{d)  the  speculum  is  half  withdrawn,  and  after  five  minutes, 
withdrawn  completely;  {e)  no  douches  are  allowed;  (/)  fresh 
applications  are  made  at  weekly  intervals  for  three  or  four 
weeks,  until  the  vaginal  secretion  is  acid,  and  then  about 
once  a  month. 

This  treatment  is  most  efficient  in  senile  vaginitis,  next  in 
ordinary  mild  vaginitis,  next  in  chronic  endometritis,  and 
least  of  all  in  vulvovaginitis  in  children. 

(4)  Routine  douches,  or  local  applications,  except  as  noted 
above,  are  a  waste  of  time. 

Mild  vaginitis  (not  senile)  responds  to  the  following:  (i) 
Hot  douching  twice  daily  of  boric  acid  (gr.  10  to  oz.  i)  or 
potassium  permanganate  1-3000;  (2)  drying  vagina  with  cotton 
and  insertion  of  vaginal  suppositories  containing  three  grains 


340  LEUKORRHEA    (tHE    WHITES) 

of  Hydrastis;  this  is  done  nightly;  (3)  powder  of  aluminum 
acetate,  one  part;  talcum  two  parts,  boric  acid  three  parts, 
applied  on  tampons  or  by  insufHation. 

(3)  Cervical  leukorrhea  is  much  the  most  stubborn  to  treat, 
especially  if  due  to  gonorrheal  endocervicitis.  The  treatment 
naturally  varies  with  the  cause.  A  lacerated  cervix  must  be 
repaired,  and  the  erosion  and  eversion  dependent  upon  the 
tear  will  disappear.  Cancer  requires  cauterization,  radium  or 
panhysterectomy.  Leukorrhea  due  to  cervical  polyps  is 
easily  checked  by  removal  of  the  polyp.  Erosion  not  due  to 
laceration  or  gonorrhea,  responds  quickly  to  8  per  cent, 
nitrate  of  silver.  The  real  problem  is  presented  by  chronic 
endocervicitis,  particularly  the  gonorrheal  type. 

Gonorrheal  Type  of  Cervical  Leukorrhea.' — (i)  Dry  treatment, 
by  aluminium  acetate,  talcum  and  boric  acid,  applied  thickly 
dusted  on  tampons.  (2)  Tampons  of  boroglycerid  25  per  cent., 
or  ichthyol  50  per  cent,  in  glycerin,  removed  at  forty-eight  hour 
intervals.  (3)  Local  applications,  on  cotton  swabs  through  a 
bivalve  speculum,  of  argyrol  25  per  cent.,  protargol  5  per  cent., 
silvol  5  per  cent.,  all  made  up  in  glycerin;  tincture  of  iodin  7 
per  cent.;  pure  formalin,  40  per  cent,  solution  of  formaldehyd; 
iodin  7  per  cent.,  carbolic  acid  pure,  equal  parts.  These 
applications  are  made  with  uterine  applicators  thinly  wound 
with  cotton,  saturated  with  the  solution  to  be  used  and  carried 
up  to  the  internal  os  The  solution  is  then  made  by  rotating 
the  applicator,  always  in  the  direction  the  cotton  has  been  wound 
on  it.  The  last  three  are  the  most  efficient,  but  likely  to  be 
painful,  and  a  cotton  pledget  should  be  packed  in  the  posterior 
vaginal  vault  to  protect  against  leakage.  These  applications 
are  made  twice  weekly,  over  periods  of  several  weeks.  (4) 
Electricity  with  copper  uterine  electrode,  positive  pole  to  the 
uterine  sound,  using  a  40  milliampere  galvanic  current  for 
forty-five  minutes  twice  weekly.  (5)  Instillations  into  the 
cervical  canal  of  5  per  cent,  silvol  or  25  per  cent,  argyrol  or 
50  per  cent,  ichthyol  pastes,  made  with  a  slowly  soluble  base 
and  injected  by  means  of  an  instillating  syringe.     For  technic 


TREATMENT  34I 

see  Chapter  VI.  (6)  Radium- — 50  mg.  screened  by  i  mm.  plati- 
num or  brass  and  encased  in  a  finger-cot,  inserted  to  the  level 
of  the  internal  os.  The  external  os  is  closed  by  a  suture,  which 
includes  the  end  of  the  finger-cot;  the  radium  is  removed  after 
eighteen  hours.  (7)  Vaccines — mixed  autogenous,  so  as  to  be 
representative  of  the  vaginal  flora.  (8)  Brewer's  yeast,  3^^ 
ounce  poured  in  the  vagina  and  held  in  by  a  large  wool  tampon 
for  twenty-four  hours  sometimes  works  well,  but  is  not  to  be 
depended  upon.  The  same  is  true  of  lactic  acid  bacilli  tablets, 
as  described  under  senile  vaginitis.  (9)  Vaginal  douching,  except 
for  cleanliness,  is  useless.  (10)  Stubborn  cases  will  require 
surgical  relief,  either  Schroder's  operation  of  excision  of  the 
mucosa  (likely  to  be  followed  by  a  secondary  dysmenorrhea 
from  stenosis)  or  much  better  amputation  of  the  cervix  at  the 
level  of  the  internal  os.  This  latter  is  efficient,  but  any  future 
pregnancy  is  very  liable  to  abort. 

(4)  Uterine  leukorrhea  is  uncommon.  The  treatment  varies 
with  the  cause.  Senile  atrophy  of  the  endometrium,  if  a  cause 
of  discharge  requires  dilatation  and  curettage  and  application 
to  the  uterine  cavity  of  tincture  of  iodin  7  per  cent,  and  pure 
carbolic  acid  equal  parts,  but  this  should  rarely  be  needed. 
Incomplete  abortion  is  cleaned  out  with  placental  forceps; 
cancer  requires  hysterectomy;  sloughing  fibroid  polyps  are 
removed  by  dilatation  of  the  canal  and  placental  forceps. 

Dilatation  and  curettage  for  gonorrheal  infection  is  to  be 
avoided  as  it  is  very  likely  to  result  in  a  pyosalpinx.  The  best 
treatment,  locally,  for  uterine  leukorrhea,  except  for  cases  due 
to  cancer  or  tuberculosis,  is  instillation  into  the  uterine  cavity 
of  25  per  cent,  argyrol,  5  per  cent,  silvol  or  5  per  cent,  protargol, 
prepared  in  glycerin.  Vaginal  douches  are  useless,  except 
for  cleanliness. 

(5)  Tubal  leukorrhea  comes  only  from  hydrosalpinx  or  pyo- 
salpinx, draining  through  the  uterine  cavity  and  requires 
abdominal  section  and  removal  of  the  affected  tube. 

(6)  Leukorrhea  in  virgins  is  most  commonly  due  to  displace- 
ment of  the  uterus  or  anemia  (chlorosis)  and  on  correction  of 


342  LEUKORRHEA    (tHE    WHITES) 

the  primary  cause  will  disappear.  When  it  occurs  without 
demonstrable  cause,  the  treatment  is: 

(i)  Iron  and  arsenic  tonics;  (2)  laxatives,  to  produce  two 
soft  movements  a  day;  (3)  ergotin  gr.  3^^,  pituitrin  }-^  milhypo- 
dermically  daily  for  five  or  six  doses,  to  diminish  uterine  con- 
gestion; (4)  in  chronic  cases,  dilatation  of  the  uterine  canal 
and  application  of  tincture  of  iodin  and  carbolic  acid  equal 
parts,  to  the  uterine  cavity. 

Prognosis.  — Many  cases  of  leukorrhea  respond  promptly 
to  treatment;  many  are  distressingly  chronic,  especially  chronic 
gonorrheal  endocervicitis.  Relapses  after  apparent  cure  are 
common. 


-    CHAPTER  XVIII 
DISEASES  OF  THE  BREAST 
I.  ANOMALIES  OF  DEVELOPMENT 

Absence  (Amazia). — The  breasts  are  never  microscopically- 
absent.  While  there  may  be  no  gross  evidence  of  any  gland 
tissue,  it  is  said  that  traces  may  always  be  found,  by  micro- 
scopical examination.  This  is,  of  course,  of  no  clinical  impor- 
tance.    Incomplete  development  is  called  micromazia. 

Supernumerary  breasts  (polymazia)  are  not  uncommon. 
In  the  embryo  of  six  weeks,  there  is  a  line  of  cells  running  from 
the  axilla  to  the  groin — the  crista  lactea.  From  the  thoracic 
portion  of  this  the  breasts  are  developed.  The  extension  of 
the  crista  lactea  into  the  axilla  is  the  most  frequent  site  of 
accessory  breasts,  though  they  may  be  situated  anywhere. 
Each  gland  may  have  its  own  nipple  and  secrete  milk  during 
lactation.  The  "swollen  gland  in  the  axilla"  complained  of 
by  so  many  patients  after  delivery,  is  simply  an  accessory 
breast. 

Supernumerary  nipples  are  known  as  polythelia. 

IL  ABNORMALITIES  OF  THE  NIPPLE 

Although  many  of  the  abnormalities  mentioned  in  this 
chapter  are  met  chiefly  as  complications  after  delivery,  the 
author  has  thought  it  best  to  include  them  in  this  place, 
rather  than  limit  the  subject  to  those  remote  from  child-birth. 

The  most  important  of  the  abnormalities  of  the  nipple  are  (i) 
Fissured  or  cracked  nipple;  (2)  inverted;  (3)  stunted;  (4) 
hollow;  (5)  mulberry;  (6)  conical;  (7)  mushroom. 

The  inflammation  of  the  nipple,  associated  with  fissure,  is 
called  mammillitis. 

343 


344 


DISEASES    or   THE  BREAST 


Fissured  nipple  most  often  occurs  in  pregnancy,  or  the 
puerperium,  from  lack  of  cleanliness  or  rubbing  of  clothing. 
It  is  rare  at  other  times. 

It  is  most  common  during  lactation,  in  primiparae,  in  blonds  or 
red-haired  women  rather  than  brunettes  and  in  any  deformity 
of  the  nipple  itself.  If  the  condition  occurs  in  pregnancy, 
cleanliness  and  protection  by  a  leaden  nipple-shield  will  usually 
sufl&ce. 


V/i^/e/^: 


HROOMXr 
Fig.   141. — Faulty  development  of  the  nipple.      {Dickinson.) 

Symptoms. — (i)  Intense  pain  on  nursing  and  (2)  a  visible 
crack  in  the  skin.  This  fissure  usually  runs  around  the  base 
of  the  nipple,  at  its  lower  border,  but  may  occur  as  a  vertical 
fissure  dividing  the  nipple  or  as  an  ulcer  anywhere  on  its 
surface.  If  not  easily  visible,  a  reading  magnifying  glass 
should  be  used  to  search  for  it.  In  any  case  of  painful  nursing, 
a  fissure  should  be  looked  for,  at  once.  The  fissure  often  bleeds 
when  the  child  is  nursed,  and  if  this  blood  is  swallowed  by  the 
child,  it  will  appear  in  the  stools — meleua  spuria. 

Treatment. — If  the  nipples  are  sore  in  pregnancy,  and  no 


ABNORMALITIES    OF    THE    NIPPLE  345 

actual  fissure  is  visible,  they  should  be  kept  scrupulously 
clean,  protected  by  a  leaden  nipple-shield  and  witch-hazel 
applied  to  them  twice  daily. 

If  the  fissure  appears  during  lactation,  scrupulous  cleanliness 
is  imperative.  The  nipple  is  protected  during  nursing  by  a 
nipple-shield  (either  the  Phoenix  or  Infantibus — the  latter 
much  the  best).  The  nipple  is  washed  off  with  boric  acid 
solution  before  and  after  each  nursing.  After  nursing  dry  and 
equal  parts  of  subnitrate  of  bismuth  and  castor  oil  is  applied. 


Fig.  142. — Leaden  nipple-  Fig.  143. — Nipple- 

shield.      {B.  C.  Hirst.)  shield.    (Phoenix.) 

All  these  applications  are  made  with  sterile  cotton  pledgets. 
The  nipples  are  then  covered  with  sterile  gauze  and  a  Murphy 
breast  binder  applied.  Alternative  applications  are  com- 
pound tincture  of  benzoin,  applied  to  the  fissure  itself;  ichthyol 
I  dram  in  i  ounce  each  of  glycerin  and  olive  oil;  solid  stick 
nitrate  of  silver  to  the  fissure. 

It  is  not  safe  for  the  child  to  nurse  without  the  protection 
shield  until  forty-eight  hours  after  the  fissure  has  apparently 
healed.  Should  the  fissure  refuse  to  heal,  or  the  child  be  unable 
to  nurse  from  the  shield,  a  tetrelle  (or  Phoenix  number  3)  should 
be  used. 

This  is  a  form  of  breast-pump  in  which  the  mother,  by  a 
rubber  tube  and  mouth  piece  makes  the  necessary  suction  to 
draw  the  milk  into  the  pump,  and  the  child  withdraws  it  by  a 
separate  orifice  and  tube.     This  instrument  can  be  used  over 


346 


DISEASES    or    THE  BREAST 


Pig.  144. — Soft-rubber  nipple- 
shield  called  "Infantibus"  will 
be  tolerated  in  cases  of  sensitive 
nipples  when  the  "Phoenix" 
and  others  cannot  be  endured. 
{J.  P.  C.  Griffith.) 


long  periods,  with  little  danger  of  causing  pain,  and  for  this 
reason  is  preferable  to  any  other  form.  As  the  mother 
regulates  the  amount  of  suction,  and  can  stop  short  of  any 
degree  that  is  uncomfortable,  there  is  little  chance  of  re- 
opening  a   fissure   that  is  healing.     If  this   will  not    work 

satisfactorily,  the  child  must  be 
weaned. 

Care  of  Nipple-shields. — Shields 
must  be  washed  and  scalded  di- 
rectly after  use,  and  kept  in  a 
closed  jar  of  boracic  acid  solution 
(gr.  10  to  oz.  i)  so  that  they 
are  completely  covered  by  the 
solution.  The  shield  is  removed 
from  the  solution  with  dressing 
forceps,  and  rinsed  in  cool  sterile 
water  just  before  use. 
Danger  of  fissured  nipple  is  chiefly  infection  and  breast  ab- 
scess. 

Inverted  nipple  is  an  arrest  of  development.  It  is  of  impor- 
tance in  lactation  only.  Long-continued  use  of  the  breast- 
pump  in  pregnancy,  with  moderate  suction,  will  help  somewhat, 
suction  being  appHed  for  fifteen  to  twenty  minutes  night  and 
morning.  The  condition  is 
usually  obstinate.  Massage 
with  the  fingers  is  somewhat 
dangerous,  due  to  bruising  and 
infection.  The  breast-pump  is 
more  efficient  and  safer.  In- 
verted nipples  are  difficult  to 
keep  clean  during  lactation. 
They  are  hkely  to  fissure,  and 
it  is  impossible  for  the  child  to  nurse  without  a  nipple-shield 
or  a  tetrelle. 

Stunted  nipple  is  important  only  in  that  it  is  difficult  for  the 
child  to  nurse.     Systematic  use  of  moderate  suction  with  a 


Fig.  145. — Breast-pump. 
{Phoenix.) 


NON-INFLAMMATORY    DISEASES    OF    THE  BREAST  347 

breast-pump,  throughout  pregnancy,  will  often  cause  improve- 
ment, but  the  nipple-shield  is  usually  required  during  the 
nursing  period. 

Hollow  nipples  are  merely  a  form  of  inverted,  have  the  same 
disadvantages  and  are  treated  in  the  same  way. 

Mulberry  nipples  are  exceedingly  hkely  to  fissure  and  re- 
quire care  to  prevent  this  complication.  If  a  fissure  occurs, 
it  is  treated  as  already  described. 

Conical  nipples  make  it  somewhat  difficult  for  the  child  to 
nurse,  but  the  difficulty  is  not  a  serious  one,  and  a  nipple 
shield  is  rarely  required. 

Mushroom  nipples  have  the  same  disadvantages  as  mulberry 
— fissure — though  to  a  less  degree. 

All  the  above  'complications  are  those  of  pregnancy  and 
lactation,  and  rarely  if  ever  give  trouble  at  other  times. 

Abscess  of  the  areola  is  most  commonly  seen  in  girls  about 
puberty,  though  it  can  occur  at  any  time.  It  arises  from 
the  sebaceous  follicles,  and  requires  incision  and  drainage. 

Paget's  disease  (Malignant  Dermatitis),  is  a  chronic,  de- 
structive inflammation  of  the  nipple,  seen  usually  in  women 
past  forty-five. 

Cause  is  unknown. 

Symptoms. — ^(i)  Moist  desquamation,  followed  by  yellow 
purulent  discharge,  with  formation  of  crusts.  (2)  Under  the 
crusts,  the  surface  is  red  and  raw.  (3)  The  nipple  is  retracted 
or  destroyed,  and  the  condition  often  extends,  like  an  eczema, 
to  the  skin  of  the  breast.  It  is  a  precursor  of  carcinoma  of  the 
breast. 

Treatment  is  excision  of  the  diseased  area,  and,  if  there  are 
any  indurated  areas  in  the  breast,  removal  of  the  breast  and 
axillary  glands.  This  operation,  like  those  for  known  carci- 
noma, should  be  followed  by  x-ray  treatment  as  a  prophylactic. 

III.  NON-INFLAMMATORY  DISEASES  OF  THE  BREAST 

I.  Hypertrophy  is  rather  rare.  It  is  bilateral  and  usually 
asymmetrical,  the  condition  is  most  often  (80  per  cent.)  seen" 


348  DISEASES    OF    THE   BREAST 

in  women  under  twenty-five  years  of  age.  The  breasts  may  be 
very  large — one  of  sixty-four  pounds  being  reported.  The 
enlargement  is  usually  a  fibrous  tissue  growth,  and  during  lac- 
tation, a  profuse  flow  of  milk  is  not  the  rule.  Nursing  the 
child  has  been  a  cause  of  reduction  in  size  of  the  glands, 
hence  it  is  not  contra-indicated. 

The  process  is  benign,  and  if  the  weight  is  burdensome,  a 
supporting  binder  or,  failing  this,  amputation  are  the  only 
remedies. 

2.  Neuralgia  of  the  breast  (mastodynia)  is  most  common  in 
young  unmarried  women,  and  is  often  associated  with  disturb- 
ance of  ovarian  secretion  and  menstrual  irregularities.  The 
skin  is  hyperesthetic,  the  breast  is  tender  to  the  touch,  but 
no  organic  change  can  be  detected. 

Treatment  is:  (i)  Iron,  arsenic  and  strychnin  as  tonics;  (2) 
hypodermic  injections  of  whole  ovarian  extract,  i  mil  daily 
for  twenty-four  doses,  followed  by  series  of  twelve  doses  at 
intervals  of  several  weeks. 

IV.  INFLAMMATORY  DISEASES  OF  THE  BREAST 

Acute  inflammation  (mastitis)  is  most  common  in  nursing 
mothers.  It  occurs  occasionally  in  infancy  (in  both  girls  and 
boys)  and  at  puberty  in  girls,  as  enlargement,  induration  and 
tenderness,  persisting  for  several  weeks  and  finally  undergoing 
resolution,  though  suppuration  sometimes  takes  place.  Masti- 
tis is  also  seen  as  a  metastatic  process  in  mumps. 

The  pus'  may  be  in  the  areola,  the  subcutaneous  connective 
tissue,  the  gland  itself  and  the  connective  tissue  under  the 
breast.  The  commonest  type  is  infection  of  the  gland,  with 
secondary  involvement  of  the  connective  tissue.  The  bacteria 
responsible  are  Staphylococcus  alhus  or  aureus,  Streptococcus 
pyogenes,  pneumococcus,  colon  bacillus,  or  O'idium  albicans. 

Cause. — Dirt  in  handling,  whether  from  hands,  cloths, 
water,  clothes  or  various  applications,  is  the  chief  cause.  The 
widespread  superstition  among  the  lower  classes  that  saliva 
is  the  best  application  for  fissured  nipple  is  responsible  for  many 


INFLAMMATORY   DISEASES    OF    THE   BREAST 


349 


cases.  The  skin  of  the  areola  and  nipple  always  contains 
pathogenic  germs,  and  these  may  develop  powers  of  invasion, 
through  the  ducts  (this  will  explain  the  cases  due  to  bruising 
in  massage).  The  child  may  be  the  source  of  infection,  if  it 
has  thrush  or  stomatitis. 

Symptoms. — A  chill  and  moderate  fever  (103°)  most  com- 
monly from  the  tenth  to  twentieth  day  of  the  puerperium.  The 
breast  is  painful,  and  one  or  more  indurated  areas  can  be  felt. 


.-  -  dntramammari/  ahseess 

""  (pointing  Superfic/allyJ 

yS lib  cutaneous 
--"  'Suhtnammariy  abscess 
■^-  -Subareolar  ahseess 


jmramammari/  abscess 

'<  -  ^  \    /  (Beep  in  the  substance  of /be  breasfj 

Fig.   146  — Location  of  pus  in  a  breast  abscess.     (After  Deaver.) 

The  commonest  portion  affected  is  the  outer  lower  quadrant. 
The  temperature  and  pain  usually  subside  within  thirty-six 
hours;  if  they  continue,  suppuration  is  to  be  expected. 

Treatment. — (i)  If  the  breast  is  engorged,  massage  is  indi- 
cated, otherwise  not.  In  any  case  it  must  be  gentle;  (2) 
purgation  with  hydragogue  cathartics;  (3)  breast-binder; 
(4)  ice  bag  over  affected  area;  (5)  applications  of  saturated 
magnesium  sulphate  solution  or  dilute  lead-water  and  alcohol 
(two  ounces  lead- water  to  three  ounces  of  alcohol);  (6)  strap- 


350  DISEASES    OF    THE  BREAST 

ping  with  adhesive  straps,  if  the  extra  pressure  is  not  too  pain- 
ful. This  treatment  is  to  be  used  only  before  suppuration  is 
evident,  and  is  often  spoken  of  as  the  "abortive  treatment." 
Bier's  local  hyperemia,  by  suction  caps,  is  painful  and  ineffec- 
tual. It  is  used  with  suction  for  four-minute  periods,  with 
equal  periods  of  rest,  for  forty-five  minutes  once  daily.  The 
results  do  not  justify  its  use. 

Breast  abscess  is  a  common  sequel  of  mastitis.  As  the  area 
involved  in  the  suppurative  process  is,  at  first,  small,  but 
tends  rapidly  to  infiltrate  the  entire  breast,  it  is  important 
to  recognize  the  presence  of  pus  as  soon  as  possible.  A  breast 
abscess  is  nearly  always  multilocular  and  fluctuation  is  not 
to  be  awaited.  The  pus  is  located  above,  usually  in,  or  under 
the  gland. 

Symptoms  at  first  are  indefinite.  Pus  may  be  expected  with 
the  following  signs:  (i)  A  dusky  red  or  purple  hue  of  the  skin 
over  the  indurated  area;  (2)  edema  of  the  skin  over  the  indu- 
rated area;  (3)  fever  of  an  irregular  septic  type;  (4)  leukocytosis 
(18,000  to  22,000  on  the  average). 

Differential  diagnosis  may  be  needed,  in  rare  instances,  from 
carcinoma  of  the  breast,  tuberculosis  of  the  breast  or  actino- 
mycosis. There  is  a  type  of  carcinoma  of  rapid  growth,  first 
appearing  in  late  pregnancy  or  early  puerperium,  called 
mastitis  carcinosa.  This,  as  well  as  tuberculosis  or  actino- 
mycosis, requires  microscopic  sections  of  an  excised  portion, 
for  accurate  diagnosis. 

Treatment. — Early  opening  of  a  breast  abscess  is  imperative, 
before  wide  destruction  of  the  gland  has  taken  place.  The 
technic  is  as  follows:  (i)  General  anesthesia.  (2)  Local  surface 
cleansing  as  for  any  operation.  (3)  With  a  thin-bladed  knife, 
make  multiple  stab  wounds,  about  one-quarter  inch  long, 
opening  every  area  where  pus  is  suspected,  and  wiping  off  blade 
of  the  knife  with  an  alcohol  pad,  after  each  incision.  These 
incisions  are  to  be  made  radiating  from  the  nipple,  so  as  not 
to  cut  across  a  milk-duct;  they  should  be  entirely  within  or 
without  the  areola,  and  not  across  the  border  (as  in  healing 


INFLAMMATORY   DISEASES    OF    THE  BREAST  35 1 

the  pigment  will  follow  the  scar);  the  incisions  should  be  so 
planned  that  when  the  patient  is  out  of  bed,  all  drainage  tubes 
will  run  down  hill,  and  not  straight  across  the  breast;  and 
it  is  desirable  to  confine  all  incisions,  if  possible,  to  the  lower 
half  of  the  breast.  (4)  A  long  hemostat  is  inserted  through  each 
opening,  and  the  septa  between  the  lobes  of  pus  broken  down, 
so  as  to  make  as  nearly  as  possible  a  unilocular  abscess.  (5) 
Each  opening  is  flushed  out  with  sterile  water,  run  from  a 
fountain  syringe  by  gravity.  (6) 
Each  pair  of  openings  is  then  con- 
nected by  fenestrated  rubber 
drainage  tubing,  about  the  size 
of  a  lead  pencil.  The  tubing  is 
pulled  from  one  opening  to  the 
other  by  the  hemostat  or  clamp. 
Care  is  taken  not  to  run  the  tubes 
superficially  (as  they  will  slough 
out  and  make  ugly  scars)  or  under 
the  nipple.  (7)  Safety  pins  are 
passed  through  each  end  of  each 
tube.     (8)  The  tubes  are  flushed       Fig.    147. — Pigment    of  the 

•  ,i       i     •!  J.         i      1.  J. I.  areola  following  incisions.   (Rich- 

witn  sterile  water,  to  be  sure  they   ^^^^^^  ) 

are    patent.     (9)    The    breast   is 

dressed  with  bunched  gauze  and  a  breast  binder.     Bandages 

or  straps  are  a  nuisance. 

The  Bier  hyperemia  treatment  is  a  failure  in  the  ordinary 
breast  abscess.  It  is  fairly  effective  in  small  single  abscesses, 
but  a  much  easier,  quicker  and  less  painful  way  to  cure  a  small 
unilocular  abscess  is  to  make  a  single  small  incision  over  the 
most  prominent  part  of  the  swelling,  wash  out  the  pus,  and 
inject  a  2  per  cent,  solution  of  hegonon,  or  25  per  cent,  argyrol, 
or  5  per  cent,  silvol.  If  the  systemic  symptoms  of  a  breast 
abscess  are  severe,  and  the  pus  is  streptococcic,  intravenous 
injection  of  80  to  100  c.c.  of  antistreptococcic  serum  is  often  of 
great  value.  The  usual  time  of  healing  of  a  breast  abscess, 
properly  opened  and  drained,  is  five  to  six  weeks. 


352 


DISEASES    OF    THE   BREAST 


After-treatment. — The  drainage  tubes  are  flushed,  once  daily, 
with  sterile  water,  run  by  gravity  from  a  fountain  syringe  with 
a  medicine  dropper  attached  to  the  tube.  Only  if  the  tubes 
are  blocked  is  a  piston  syringe  used  to  force  water  through  them, 
and  as  soon  as  they  are  clear,  the  gravity  flow  is  substituted. 
No  attempt  is  made  to  remove  the  tubes  for  at  least  two  weeks, 
and  then  the  shortest  is  removed  first,  and  the  others  at  two-  or 


Fig.  148. 


-Drainage    required    in    a    case    of    mammary    abscess. 
(5.  C.  Hirst.) 


three-day  intervals;  the  sinuses  are  packed  lightly  with  gauze, 
from  each  end,  and  flushed  daily.  Small  secondary  superficial 
collections  frequently  need  opening  during  the  convalescence. 
Unless  the  nipple  ducts  have  been  blocked,  lactation  in  sub- 
sequent confinements  is  surprisingly  little  interfered  with. 


INFLAMMATORY   DISEASES    OF    THE   BREAST  353 

Postmammary  abscess  (submammary  abscess)  is  a  collec- 
tion of  pus  in  the  connective  tissue  under  the  breast,  just  over 
the  pectoral  muscles.     It  is  rare,  and  serious. 

Symptoms. — One  breast  is  more  prominent  than  the  other, 
the  whole  gland  being  lilted  off  the  chest.  There  are  no 
symptoms  of  inflammation  in  the  breast  itself,  and  very  little 
pain  on  pressure.  Systemic  symptoms  of  sepsis  are  severe, 
fever  high  and  leukocytosis  25,000  or  more. 

Diagnosis  is  best  made  by  aspiration  with  a  hypodermic 
syringe.  The  needle  should  be  of  fairly  large  caliber,  as  the 
pus  is  usually  thick. 

Treatment. — An  opening  is  made  at  the  most  dependent 
portion,  a  counter-opening  diametrically  opposite,  and  through- 
and-through  drainage  established  by  a  fenestrated  rubber  tube. 
The  after-care  is  that  of  the  ordinary  breast  abscess. 

Chronic  mastitis  occurs  in  two  forms: 

1.  Lobar  (or  circumscribed),  usually  following  trauma  or 
pregnancy.  It  is  most  frequent  in  women  near  the  menopause. 
The  lobe  involved  is  enlarged,  indurated  and  tender,  but  there 
is  no  systemic  disturbance.  It  is  exceedingly  chronic,  but 
never  suppurates. 

2.  Diffuse  (lobular  or  interstitial)  is  most  frequent  after 
lactation  or  at  the  menopause.  The  intercanalicular  connec- 
tive tissue  increases  very  markedly,  and  later  contracts, 
so  that  the  breast  is  hard  and  shrunken,  the  seat  of  small  cysts, 
and  the  nipple  depressed.  The  breast  is  painful  and  there 
is  a  watery  discharge  from  the  nipple.  The  disease  rarely 
disappears,  but  causes  atrophy  of  the  breast,  with  general 
cystic  degeneration,  and  possibly  carcinoma. 

Treatment  of  both  forms  of  chronic  mastitis  is:  (i)  Removal 
of  any  source  of  chronic  irritation,  such  as  badly  fitting 
corsets;  (2)  support  by  a  breast-binder;  (3)  local  inunction 
of  unguent,  hydrargyri  and  unguent,  belladonnae  equal  parts; 
(4)  potassium  iodid  15  grains  four  times  a  day;  (5)  amputation 
of  the  breast  if  exceedingly  painful  or  the  seat  of  gross  patho- 
logical changes. 


354  DISEASES    OF    THE   BREAST 

Chronic  suppurative  mastitis  is  distinguished  by  pus  forma- 
tion without  signs  of  inflammation.  It  follows  lactation, 
syphihs,  tuberculosis  and  actinomycosis.  The  abscess  wall  is 
very  thick,  and  the  tumor  feels  solid,  without  fluctuation.  The 
diagnosis  is  made  by  aspiration. 

Treatment. — If  small  in  extent,  incision  and  drainage,  if 
extensive,  amputation  of  the  breast. 

Tuberculosis  is  uncommon.  It  may  be  localized  (cold 
abscess)  or  diffuse  (miliary) .  It  is  usually  secondary.  Sharply 
circumscribed  areas  can  be  excised,  but  as  a  rule  amputation 
is  required. 

Syphilis  is  seen  as  mucous  patches  or  condylomata  of  the 
nipple,  or  as  gummata.  The  local  manifestations  disappear 
on  systemic  treatment. 

V.  TUMORS  OF  THE  BREAST 

Tumors  of  the  breast  are  benign  or  malignant.    ' 
Method  of  Examination. — In  palpating  the  breast  for    a 
tumor,  the  gland  should  not  be  picked  up  between  the  fingers, 
but  pressed  against  the  chest-wall  with  the  flat  of  the  hand. 

Benign  Tumors  of  the  Breast 

Fibro-adenomata  are  the  most  common  benign  tumors  of 
the  breast.  Pure  fibroma  and  pure  adenoma  are  exceedingly 
rare.  They  occur  between  puberty  and  the  thirtieth  year. 
They  are  hard,  nodular,  freely  movable,  usually  but  not  always 
painless  and  show  no  adherence  of  the  skin,  axillary  involvement 
or  effect  upon  the  general  health.  They  are  subject  to  cystic 
degeneration,  but  rarely  become  malignant.  They  often  grow 
rapidly  in  pregnancy. 

Treatment.- — (i)  Semicircular  incision  along  lower  margin  of 
breast;  (2)  breast  is  turned  back  and  the  growth  removed  by 
V-shaped  excision;  (3)  the  wound  of  excision  is  sutured,  and 
if  much  tissue  is  lost,  the  gap  can  be  filled  in  with  fat  trans- 
planted from  the  thigh  or  buttock;   (4)  the  skin  wound  is 


TUMORS   OF    THE  BREAST 


355 


sutured  by  subcuticular  stitch,  leaving  provision  for  drainage 
of  serum  at  one  corner. 

Cysts  of  the  breast  are  (i)  Retention  cysts  caused  by  blocking 
of  the  ducts  (galactocele);  (2)  involution  cysts  (in  interstitial 
mastitis  and  often  papillary),  usually  bilateral;  (3)  interacinous 
cysts  (from  lymph-spaces  and  lined  with  endothelium.  They 
have  no  connection  with  the  gland  spaces.  A  galactocele  is 
round,  painless,  near  the  nipple  and  usually  fluctuating.     The 


Pig.  149. — Removal  of   a  breast  tumor  by  elevation  of  the  breast 
and  wedge-shaped  excision.      (After   Warren.) 


treatment  required  is  incision  and  drainage.  Involution  cysts 
require  amputation  of  the  breast.  Interacinous  cysts  are 
dissected  out,  entire  if  possible.  Any  cyst  of  the  breast  should 
be  looked  upon  v/ith  suspicion,  even  though  the  microscope 
shows  no  evidence  of  malignancy.  They  are  often  in  the 
precancerous  stage,  and  the  patient  should  be  kept  under 
observation  for  several  years. 

Cystadenoma  is  the  dilatation  of  the  acini  into  multiple  cysts. 
It  occurs  between  the  thirtieth  and  fortieth  years,  is  slow  in 


356  DISEASES    OF   THE  BREAST 

growth,  large  in  size,  painless,  and  associated  with  bleeding 
from  the  nipple.  It  is  nodular  and  encapsulated,  hard,  and  in 
the  later  stages  adheres  to  the  skin  even  breaks  through  it. 
It  does  not  as  a  rule  involve  the  axillary  glands. 

Treatment. — In  the  early  stage,  removal  of  the  growth  alone; 
in  the  late  stages,  amputation  of  the  breast. 

Malignant  Tumors  of  the  Breast 

I.  Carcinoma. — Frequency. — Over  80  per  cent,  of  all  breast 
tumors  are  carcinoma.  It  is  more  frequent  in  women  who  have 
borne  children.  Any  lump  in  the  breast  must  be  regarded  as 
potentially  malignant,  until  proven  otherwise.  Cancer  is 
more  frequent  in  the  left  breast  than  the  right. 

Age  of  Patient. — The  majority  are  past  thirty-five  years  of 
age.  It  may  occur  much  earlier,  but  is  unusual  before  thirty- 
five  or  past  sixty-five. 

Causes. — (i)  Preceding  trauma  or  inflammation;  (2)  Paget's 
disease;  (3)  heredity  influence  is  slight. 

The  actual  exciting  cause  is  not  known. 

Kinds. — (i)  Acinous;  (2)  columnar  celled  or  duct  cancer; 
(3)  squamous-celled  epithelioma. 

Medullary  or  encephaloid  cancer  is  soft,  appears  at  an  earlier 
age,  grows  rapidly,  ulcerates  early,  gives  early  metastases, 
and  the  nipple  is  not  retracted.  This  is  the  type  which,  owing 
to  its  often  following  pregnancy  and  being  vascular,  is  mistaken 
for  a  breast  abscess. 

Scirrhous  or  hard  cancer  appears  later,  grows  slowly,  is  stony, 
hard  and  nodular,  the  skin  is  adherent  and  infiltrated  and  the 
whole  breast  is  movable  as  one  mass;  in  the  early  stages  per- 
pendicularly to  the  milk  ducts  but  not  parallel  to  them; 
in  the  late  stages,  after  the  pectoral  muscle  has  been  in- 
volved, up  and  down  but  not  transversely.  As  the  fibrous 
septa  of  the  breast  contract,  small  depressions  appear  in  the 
skin,  giving  it  the  appearance  of  orange  rind  or  a  pig's  skin. 
This  growth  is  most  frequent  in  the  outer  segment  of   the 


TUMORS    OF    THE  BREAST  357 

breast.  The  nipple  is  higher  on  the  affected  side,  and  the  areola 
shrunken.  A  scirrhous  cancer  is  never  large  and  in  old  women 
sometimes  shrinks  progressively  and  lasts  for  years  (atrophied 
scirrhous).  If  the  skin  is  extensively  infiltrated,  it  is  called 
cancer  en  cuirasse. 

Symptoms. — (i)  A  growth  in  the  breast,  answering  one  of  the 
descriptions  just  given;  (2)  rapid  growth  if  medullary,  slow 
if  scirrhous;  (3)  often  a  thin  bloody  discharge  from  the  nipple; 
(4)  pain  is  absent  at  first,  but  later  is  very  severe,  due  to  axillary 
involvement;  (5)  ulceration  is  preceded  by  a  purple  discolora- 
tion of  the  skin;  (6)  cachexia  is  a  late  symptom;  (7)  the  axillary 
lymph-glands  are  involved  early,  and  later,  with  the  supra- 
clavicular, become  palpable;  (8)  solid  edema  of  the  upper 
extremity,  caused  by  pressure  on  the  axillary  vein  and  lymph- 
vessels. 

When  ulceration  takes  place,  the  scirrhous  ulcer  has  hard, 
uneven,  everted  margins,  is  deep  and  has  an  offensive  bloody 
seropurulent  discharge. 

Diagnosis. — Any  suspicious  lump  in  the  breast  should  be 
excised  and  examined  microscopically.  This  is  vitally  impor- 
tant in  all  women  past  thirty-five.  By  the  time  a  diagnosis 
can  be  established  by  symptoms  alone,  it  is  usually  too  late 
for  a  successful  operation. 

Metastasis  takes  place:  (i)  The  axillary  lymph-glands;  (2) 
the  supraclavicular  lymph-glands;  (3)  the  anterior  and  pos- 
terior mediastinum;  (4)  to  the  opposite  breast  and  axilla. 

Treatment  is  early  and  complete  removal  of  the  breast, 
pectoral  muscles,  axillary  glands  and  fat  and  supraclavicular 
glands.  The  huge  wound  is  closed  by  undermining  of  the  skin 
and  bringing  the  flaps  together  with  interrupted  silkwormgut 
sutures.  The  axilla  is  drained  for  forty-eight  hours,  by  rubber 
tissue  or  a  tube  through  a  stab  wound.  If  the  wound  edges 
cannot  be  brought  together,  the  gap  is  allowed  to  granulate 
and  skin-grafted  later  if  necessary. 

Inoperable  cases  are:  (i)  Those  with  extensive  involvement  of 
axillary   or   supraclavicular   glands;    (2)    cancer   en   cuirasse; 


35S  DISEASES    OF    THE  BREAST 

(3)  those  with  visce.al  involvement;  (4)  atrophic  scirrhous 
cancer  in  old  women. 

Treatment. — (i)  Local  cauterization;  (2)  fulguration,  usually 
under  chloroform  and  never  ether,  because  ether  vapor  is 
inflammable;  (3)  a;- ray  or  radium,  (4)  morphin  in  doses 
sufficient  to  control  the  pain.  The  various  cancer  serums, 
cauterizing  pastes;  Coley's  fluid,  injection  of  drugs  like  pyok- 
tanin,  thiosinamin,  methyl-violet  are  useless. 

After-treatment. — Every  case  of  cancer  of  the  breast,  should 
be  treated,  after  operation,  by  .r-ray  as  a  palliative  measure. 

Prognosis. — In  untreated  scirrhous  cancer,  expectation  of  life 
is  two  or  three  years;  in  medullary  cancer,  eight  to  twelve 
months.  After  operation  20  per  cent,  remain  well  after  three 
years.  A^^ter  operation,  immediate  edema  of  the  arm  on  the 
same  side  is  a  favorable  sign,  showing  complete  removal  of  the 
lymphatics;  late  edema  is  uniavorable,  due  usually  to  recur- 
rence. Surprising  muscular  action  in  the  arm  is  preserved  or 
acquired,  even  after  most  extensive  operations.  The  mortality 
of  the  operation  itself  is  less  than  3  per  cent. 

2.  Sarcoma  of  the  breast  forms  less  than  5  per  cent,  of  breast 
tumors.  Sarcoma  appears  usually  between  the  ages  of  twenty- 
five  and  thirty;  it  is  encapsulated,  grows  rapidly;  is  usually 
softer  than  cancer,  causes  distention  of  the  overlying  veins, 
does  not  invade  the  axilla  until  ulceration  has  taken  place,  but 
does  give  early  visceral  metastasis. 

Kinds. — Equally  divided  between  small  round-celled  and 
spindle-celled.     Inflammation  and  suppuration  are  common. 

Differential  Diagnosis. — (i)  As  given  above;  (2)  is  more 
movable  than  cancer;  (3)  does  not  retract  the  nipple;  (4)  does 
not  infiltrate  or  thicken  the  skin;  (5)  causes  profuse  hemorrhage 
from  ulceration. 

Treatment  is  the  same  as  for  cancer. 

Prognosis  is  very  grave.  The  vast  majority  die  from  recur- 
rence or  visceral  metastasis. 


CHAPTER  XIX 
DISEASES  OF  THE  RECTUM 

Diseases  of  the  rectum  are  very  much  the  same  in  both  sexes, 
but  the  frequency  of  rectal  complications  in  pelvic  diseases 
in  women  renders  a  short  synopsis  of  the  commoner  ones  advis- 
able in  any  work  on  gynecology. 

Methods  of  Examination. — Rectal  examination  is  best  made 
with  the  patient  in  the  Sims  or  knee-chest  position,  the  latter 
particularly  for  specular  and  proctoscopic  examination. 

1.  Inspection  of  the  external  parts  for  fistula,  fissure,  hemor- 
rhoids bleeding  or  other  discharge,  and  any  other  local  con- 
dition. By  having  the  patient  strain,  prolapse  of  the  rectum 
becomes  evident,  as  do  internal  hemorrhoids  and  some  polyps. 

2.  Digital  examination  permits  exploration  of  the  rectum  to 
the  length  of  the  finger  only,  about  four  inches.  A  rubber 
glove  is  essential.  The  index  finger  is  anointed  with  vaselin, 
and  gently  inserted  through  the  sphincter,  at  first  forward 
and  then  back  towards  the  sacrum.  In  this  way,  polyps, 
internal  hemorrhoids,  foreign  bodies,  stricture  or  any  other 
internal  abnormality  may  be  felt.  If  pressure  is  made  on  the 
lower  abdomen  with  the  other  hand,  by  pushing  the  bowel 
downward,  the  reach  of  the  examining  finger  is  slightly 
increased. 

3.  Specula  for  rectal  examination  are  either  cylindrical  or 
bivalve.  They  are  best  used  in  the  knee-chest  position,  but 
permit  of  a  limited  view  only  of  the  rectum.  Light  is  reflected 
from  a  head  mirror  or  headlight. 

4.  A  proctoscope  is  merely  a  long  cylindrical  speculum  (8 
inches);  a  sigmoidoscope  a  still  longer  one  (14  inches)  both 
being  provided  with  obturators  and  having  an  electric  light 
at  the  distal  end. 

359 


360  DISEASES    OF    THE    RECTUM 

Technic. — i.  The  patient  is  arranged  in  the  knee-chest 
or  Sims  position;  anesthesia  is  unnecessary. 

2.  The  instrument,  with  the  light  removed,  is  sterihzed  by 
boihng. 

3.  The  light  is  inserted  and  connected,  the  obturator  in- 
serted, and  the  instrument  greased  with  vaseHn. 

4.  The  instrument  is  gently  inserted  past  the  internal 
sphincter,  the  obturator  removed. 

5.  If  the  rectum  does  not  distend  under  atmospheric  pressure 
a  plug  with  glass  window  is  inserted  in  the  proximal  end  and  by 
means  of  a  hand  bulb,  the  rectum  is  distended  with  air  and  the 
instrument  passed  to  its  full  length. 

6.  The  whole  rectum  is  carefully  inspected  as  the  instrument 
is  withdrawn. 

7.  Applications  may  be  made  to  the  rectal  mucosa  by  long 
applicators,  through  the  barrel  of  the  instrument. 

5.  If  the  rectum  is  filled  with  bismuth  mixture,  or  a  solution 
of  10  per  cent,  thorium  nitrate,  the  size  and  shape  of  the  rectum 
and  the  presence  of  fistulse  or  diverticula  can  be  shown  by  :v-ray. 

I.  CONGENITAL  MALFORMATIONS 

During  development,  the  gut  and  genito-urinary  canal  open 
into  a  common  passage,  the  cloaca.  Later  the  perineum  is 
formed,  by  the  growth  of  a  posterior  and  two  lateral  folds,  and 
the  gut  provided  with  its  separate  outlet.  The  proctodeum 
is  a  depression  extending  in  from  the  perineum,  until  it  meets 
the  rectum,  and  marks  the  site  of  the  anus.  Errors  in  develop- 
ment cause  the  following:  (i)  Imperforate  anus,  where  the  rec- 
tum is  complete  but  the  proctodeum  is  absent;  (2)  imperforate 
rectum,  where  the  rectum  and  proctodeum  are  both  developed 
but  do  not  meet;  (3)  absent  rectum,  where  the  rectum  ends 
high  up  under  the  pelvic  brim.  All  these  must  be  corrected 
immediately  after  birth,  as  they  are  ^etal  complications,  and 
have  no  place  in  the  adult;  (4)  an  imperfect  septum  dividing 
the  cloaca,  results  in  the  rectum  opening  into  the  bladder 
(anus  vesicalis) ;  urethra  (anus  urethraHs) ;  or  the  vagina  (anus 


PISTULA   IN    ANO  361 

vaginalis  or  vestibularis).  These  abnormalities  are  usually- 
corrected  during  infancy  or  childhood  and  are  rarely  seen  in 
adult  life. 

IL  FISSURES  OF  THE  ANUS 

This  is  often  a  complication  of  hemorrhoids,  fecal  impaction 
and  passage  of  hardened  feces,  or  proctitis. 

Symptoms. — (i)  Burning  pain  on  defecation,  and  often  on 
coughing  or  sneezing;  (2)  often  a  single  "sentinel"  pile  at  its 
outer  extremity;  (3)  streaks  of  pus  or  blood  on  the  fecal  column 
when  it  is  passed;  (4)  constipation  encouraged  because  of  the 
pain  of  a  movement;  (5)  spasmodic  contraction  of  the  sphincter. 

Diagnosis. — By  separating  the  folds  of  the  anus  the  fissure 
can  usually  be  seen.  If  not,  the  patient  is  examined  with  a 
bivalve  rectal  speculum. 

Prognosis. — May  heal  spontaneously.  Some  are  chronic 
ulcers  which  persist  for  long  periods. 

Treatment. — (i)  As  an  office  measure,  cocamize  the  fis'Sure 
with  10  per  cent,  cocain  solution  and  apply  the  solid  stick 
nitrate  of  silver;  repeated  three  times  weekly  until  the  pain  on 
defecation  disappears;  (2)  laxatives  sufficient  to  give  two  soft 
movements  daily;  (3)  if  the  above  fails,  the  patient  is  anes- 
thetized and  the  sphincter  forcibly  dilated,  with  the  thumbs. 
During  the  resulting  paralysis  for  five  or  ten  days,  the  ulcer 
usually  heals;  (4)  coexisting  piles  should  be  removed  at  the 
same  time.  If  there  is  any  difficulty,  in  office  treatment,  in 
exposing  the  fissure,  pressure  by  the  forefinger  in  the  vagina 
can  be  used  to  evert  the  rectum  through  the  sphincter.  For  this 
the  patient  is  in  the  right  Sims'  position,  so  that  the  left 
hand  is  used  for  everting  and  the  right  for  application;  (5) 
a  large  ulcerated  fissure  may  require  excision,  but  this  is  rare. 

IIL  FISTULA  IN  ANO 

Fistula  in  ano  is  nearly  always  caused  by  the  rupture  of  an 
abscess,  the  sinus  refusing  to  heal  because  of  poor  drainage, 
tortuous   course   and   constant   reinfection   from    the   bowel. 

About  one-half  the  cases  are  tubercular. 


362 


DISEASES    OF   THE   RECTUM 


There  are  three  kinds  of  fistulcc: 

1.  Blind  External. — A  sinus,  which  opens  externally  but  does 
not  communicate  with  the  bowel.  It  is  short  and  near  the 
anus  when  due  to  an  anal  abscess;  deeper  and  further  from  the 
anus  when  due  to  an  ischiorectal  abscess. 

2.  Blind  Internal. — Also  a  sinus,  which  opens  into  the  bowel, 
but  has  no  opening  on  the  skin  externally.     It  is  the  rarest, 

and  is  usually  on  the  pos- 
terior or  lateral  wall  of 
the  rectum. 

3.  Complete. — With  an 
opening  both  external  and 
internal  occurs  in  75  per 
cent,  of  cases.  It  is  usually 
due  to  an  ischiorectal  ab- 
scess, the  internal  opening 
being  about  one  and  one- 
half  inches  from  the  anus. 
Symptoms. — (i)  Pain 
during  defecation;  (2)  ten- 
esmus; (3)  purulent  dis- 
charge; (4)  in  complete  cases,  escape  of  gas  and  feces  through 
the  fistula;  (5)  often  recurrent  abscesses,  due  to  blocking  of  the 
tract  and  re-infection.  As  these  often  rupture  through  new 
tracts,  they  cause  branching  of  the  sinus. 

Diagnosis  is  made  by  inspection  and  probing  if  the  fistula 
has  an  external  opening;  by  rectal  speculum  and  digital  explor- 
ation if  it  is  blind  internal.  By  digital  examination  can  be  felt 
spasm  of  the  sphincter,  the  cord-like  tract  of  the  fistula  and 
sometimes  its  orifice. 

Treatment. — (i)  Always  examine  lungs  for  phthisis  and  if 
present  and  active,  avoid  operation  if  possible;  (2)  patient  is 
arranged  in  the  lithotomy  position  and  anesthetized;  (3) 
a  grooved  director  is  passed  through  the  fistula  into  the  rec- 
tum, between  the  two  sphincters;  (4)  the  overlying  tissues  are 
cut  through,  the  external  sphincter  cut  once  at  right  angles  to 


Pig.  150. — Forms  of  rectal  and 
anal  fistulae.  Blind  internal,  blind 
external,  and  complete. 


HEMORRHOIDS    (piLES)  363 

its  fibers.  Incontinence  need  not  be  feared,  provided  the 
internal  sphincter  is  not  cut,  and  the  external  cut  but  once; 
(5)  all  branching  sinuses  are  opened,  and  all  hard  cicatricial 
tissues  cut  away  with  scissors;  (6)  the  bleeding  is  checked  and 
the  wound  packed  with  iodoform  gauze;  (7)  blind  fistula  are 
best  converted  into  complete  fistulse,  and  healed  as  described; 
the  grooved  director  should  always  be  brought  out  between 
the  two  sphincters;  (8)  the  bowels  are  kept  locked  with  opium 
suppositories  for  four  days;  (9)  on  the  fourth  day,  the  patient 
is  given  an  ounce  of  castor  oil,  and  when  a  desire  for  evacuation 
occurs,  the  packing  is  removed  and  she  is  given  one-half  pint 
of  sweet  oil  by  enema;  (10)  after  each  defecation  the  packing 
is  removed,  the  wound  irrigated,  and  the  packing  replaced; 
(11)  time  of  convalescence  is  about  three  to  four  weeks.  If 
the  fistula  is  lined  with  mucous  membrane,  it  must  be  com- 
pletely excised.  The  internal  sphincter  should  never  be  cut,  and 
if  the  fistula  opens  into  the  bowel  above  the  internal  sphincter, 
its  lower  portion  only  should  be  dissected  out. 

IV.  FOREIGN  BODIES  IN  THE  RECTUM 

Foreign  bodies  are  occasionally  found,  having  been  inserted 
by  degenerates  or  insane  persons,  or  have  been  swallowed. 
Symptoms  are  tenesmus,  bleeding  (due  to  ulceration)  and 
obstruction  varying  with  the  size  of  the  foreign  body. 

Diagnosis  is  made  by  digital  examination,  speculum  or 
x-ray. 

Treatment. — Removal  by  finger  or  forceps,  through  a 
speculum,  usually  under  anesthesia.  Large  bodies  may  require 
splitting  of  the  anus. 

V.  HEMORRHOIDS  (PILES) 

Hemorrhoids  are  varicose  veins  about  the  lower  end  of  the 
rectum.  ' 

Kinds. — (i)  External  hemorrhoids  at  the  margin  of  the  anus 
are   covered   with   skin.     They   originate   from    the    inferior 


364 


DISEASES    OF    THE   RECTUM 


hemorrhoidal  plexus,  and  consist  of  varicose  veins,  surrounded 
by  connective  tissue.  They  are  likely,  especially  in  labor, 
to  become  inflamed,  painful  and  thrombotic. 

2.  Internal  hemorrhoids  originate  from  the  superior  hemor- 
rhoidal plexus,  are  covered  by  mucous  membrane,  and  consist 
of  varicose  veins,  connective  tissue  and  a  few  small  arterial 
twigs.  They  are  likely,  under  straining,  to  protrude  through 
the  sphincter,  which  then  closes  down  and  strangulates  them. 


iternal 
emorrhoid 


Exferrfal 

^&no- external  Hemorr4iold  Hemorrhoid 

Fig.   151. — -Location,    of  hemorrhoids.      {After  Peyuiington.) 


External  and  internal  hemorrhoids  often  co-exist  in  the  same 
case. 

•Causes. — ^(i)  Chronic  constipation,  with  its  attendant 
straining  at  stool,  is  much  the  commonest  cause;  (2)  laceration 
of  the  perineum,  rectocele  or  prolapse  of  the  uterus;  (3)  any 
cause  (such  as  pelvic  inflammation,  obstruction  to  the  portal 
circulation,  rectal  disorders)  which  produces  chronic  pelvic 
congestion;  (4)  they  are  the  rule,  though  often  temporary,  in 
pregnancy. 

Histology. — The    veins    run    longitudinally    between     the 


HEMORRHOIDS    (piLES)  365 

mucosa  and  the  muscle,  and  form  a  complicated  plexus  above 
the  anus.  They  have  no  valves,  and  are  one  of  the  principal 
communications  between  the  portal  and  systemic  circulations. 

Symptoms. — External  hemorrhoids  csiuse  few  symptoms,  other 
than  slight  itching,  unless  they  become  inflamed.  Then  they 
are  distended,  tense,  bluish  masses,  painful  to  the  touch,  and 
they  cannot  be  emptied  by  pressure.  Repeated  attacks  of 
inflammation  cause  permanent  thickening  of  the  pile. 

Internal  hemorrhoids  (bleeding  piles)  cause:  (i)  Pain,  worse 
on  defecation  and  in  direct  ratio  to  the  degree  of  constipation; 
(2)  sense  of  fulness  in  rectum  at  all  times;  (3)  bleeding  usually 
slight  but  may  be  very  severe;  (4)  usually  a  mucous  discharge; 
(5)  when  inflamed,  they  project  through  the  sphincter  and  are 
intensely  painful;  (6)  ulceration  is  common. 

Diagnosis. — External  hemorrhoids  are  obvious  on  inspection. 

Internal  piles  are  often  made  visible  by  straining,  can  be 
felt  by  digital  examination  or  seen  through  a  speculum.  By 
placing  the  patient  in  the  Sims  position,  the  forefinger  can 
exert  sufficient  pressure  through  the  vagina  to  roll  the  entire 
anal  canal  out  through  the  sphincter,  into  view,  especially 
if  the  patient  is  asked  to  strain  at  the  same  time. 

Treatment. — External  hemorrhoids,  when  not  inflamed,  re- 
quire: (i)  Laxatives;  (2)  washing  the  anal  region  after  each 
defecation;  (3)  the  use  of  soft  paper  or  cotton  directly  after 
defecation;  (4)  local  application  of  witch-hazel  and  water 
equal  parts.  If  they  are  inflamed  and  thrombotic,  they  must 
be  incised,  evacuated  and  packed,  under  anesthesia. 

Internal  Hemorrhoids.     Palliative  Treatment. — (i)  Laxatives. 

(2)  Bland  diet,  with  avoidance  of  highly  spiced  food  or  alcohol. 

(3)  Cleanliness  as  described  above.  (4)  Local  applications, 
two  very  satisfactory  examples  of  which  are  the  following: 

Ext.  hamamelis,  fld.  oz.  i 

Ext.  Hydrastis  fld. 

Tinct.  benzoin  comp.  aa  oz.  3^^ 

Tinct.  belladonnas  dram  i 

01.  olivse  (carbol.  5  per  cent.)  q.  s.  ad.  oz.  3 


366  Diseases  of  the  rectum 

Apply  frequently,  both  externally  and  internally  (Adler) 

Cocain  hydrochlorat  gr.  10 
Unguent,  galli  (nutgall) 
Unguent,  belladonnse  aa  oz.  i 

Apply  thickly,  with  finger  protected  by  finger-cot,  inside 
rectum,  four  times  a  day. 

The  latter  is  the  most  useful,  if  there  is  much  pain.  (5) 
Whenever  the  piles  prolapse,  they  should  be  replaced,  with 
the  finger  protected  by  glove  or  finger-cot. 

Operative  Treatment. — Is  indicated  when:  (i)  Excessive 
pain;  (2)  excessive  or  prolonged  bleeding;  (3)  repeated  strangu- 
lation; (4)  ulceration;  (5)  repeated  inflammation. 

Preparatory  treatment  for  operation  consists  of:  (i)  Laxative — 
not  purge,  forty-eight  hours  before  operation;  (2)  enemas 
thirty-six,  twenty-four  and  twelve  hours  before  operation; 
(3)  paregoric  drams  2,  two  hours  before  operation;  (4)  regular 
preparation  for  anesthesia. 

Operation. — (i)  Injection  of  boiling  water,  done  under  local 
anesthesia  (10  per  cent,  cocain),  several  drops  being  injected, 
by  a  hypodermic,  into  each  pile  at  intervals  of  a  week. 

(2)  Injection  of  two  drops  of  10  per  cent,  carbolic  acid 
solution,  in  the  same  way.  These  two  can  be  used  as  office 
treatment,  but  are  not  routinely  efficient. 

3.  Clamp  and  Cautery. — (i)  The  patient  is  arranged  in  the 
Sims  or  dorsal  position  and  anesthetized;  (2)  the  sphincter  is 
thoroughly  dilated;  (3)  a  pile  is  caught  with  hemostatic  forceps 
and  pulled  down;  (4)  a  Smith's  clamp,  with  ivory  base  next  to 
the  mucous  membrane,  is  applied  and  screwed  tight;  (5)  the 
top  of  the  pile  is  removed  with  scissors  and  the  base  seared  with 
a  cautery  at  a  dull  red  heat  Ctoo  much  heat  causes  hemorrhage) ; 
(6)  the  clamp  is  removed  and  all  other  piles  are  treated  in  the 
same  way.  The  Downes  electrothermic  angiotribe  is  a  neat 
instrument  for  applying  heat  and  pressure  simultaneously. 
The  pile  is  brought  down  in  the  same  way,  the  clamp  applied 
and  the  special  guard  underneath  it.     Wet  gauze  is  then  placed 


HEMORRHOIDS    (PILES)  367 

under  the  clamp  and  protector  and  the  current  turned  on  for 
thirty  seconds,  counted  from  the  time  audible  sizzhng  begins. 
The  pile  is  cut  away  thirty  seconds  after  the  current  has  been 
turned  of  and  the  clamp  and  protector  are  then  removed. 

4.  Ligature. — (i)  The  patient  is  treated  like  the  clamp  opera- 
tion until  the  pile  is  brought  down;  (2)  a  gutter  is  cut  in  the 
skin  with  scissors,  around  the  base  of  the  pile;  (3)  the  pile  is 
transfixed  with  a  needle  armed  with  number  3  chromic  catgut, 
tied  off  in  the  gutter  and   emoved. 

Both  these  operations  cause  some  sloughing  or  swelling,  but 
the  end  results  are  satisfactory. 

5.  The  Whitehead  operation  is  useful  only  when  the  entire 
anus  is  surrounded  by  a  mass  of  piles.  A  circular  incision  is 
made  at  the  junction  of  the  skin  and  mucosa,  the  pile-bearing 
area  resected,  and  the  mucosa  stitched  to  the  skin. 

The  operation  is  rarely  to  be  recommended.  It  is  often 
followed  by  stricture  and  incontinence. 

After-treatment: — (i)  At  the  end  of  the  operation,  insert  a 
rectal  suppository  of  extract  of  opium  gr.  i,  iodoform  gr.  5; 
(2)  hypodermics  of  morphin  or  heroin  will  be  required  in  most 
cases,  for  the  first  forty-eight  hours;  (3)  swelling  is  controlled 
by  hot  applications;  (4)  a  rectal  tube  left  in  the  rectum  pro- 
vides for  the  painless  escape  of  flatus;  (5)  the  patient  wears  a 
sterile  pad,  and  the  perineum  is  irrigated  with  lysol  solution 
(one  dram  or  two  pints)  four  times  daily;  (6)  the  bowels  are 
locked  for  four  days  and  then  moved  with  castor  oil  oz.  i, 
followed  by  an  oil  enema  when  a  movement  is  imminent;  (7) 
catheterization  is  needed  for  several  days,  due  to  retention 
of  urine  from  reflex  pain,  and  should  be  done  every  eight 
hours. 

In  patients  who  have  perineal  tears,  any  operation  for 
hemorrhoids  should  be  accompanied  by  perineorrhaphy,  other- 
wise return  of  the  hemorrhoids  is  certain. 

Rectal  bleeding  is  usually  neghgible,  if  proper  technic 
has  been  followed.  If  it  is  excessive,  it  is  best  controlled  by 
a  rectal  tube  surrounded  by  gauze,  or  by  packing  the  rectum 


368  DISEASES    OF   THE    RECTUM 

with  gauze  for  twenty-four  to  thirty-six  hours,  the  gauze  being 
then  very  gently  and  slowly  removed. 

VL  PROCTiriS  (INFLAMMATION  OF  THE  RECTUM) 

This  is  not  common. 

Causes. — (i)  Polyps;  (2)  colitis;  (3)  infected  syringe  nozzle 
in  giving  enemas;  (4)  gonorrhea;  (5)  dysentery;  (6)  foreign 
bodies;  (7)  infected  hemorrhoids. 

Symptoms  are  (i)  tenesmus;  (2)  frequent  defecation;  (3) 
discharge  of  mucus,  pus  or  blood;  (4)  fever,  in  acute  cases. 
The  rectal  mucosa  often  prolapses  and  there  is  always  danger 
of  ulceration  and  stricture. 

Diagnosis. — By  proctoscopy  the  red,  swollen  mucosa, 
covered  with  pus  or  mucus  can  be  seen. 

Treatment  is  (i)  removal  of  the  cause;  (2)  rest  in  bed;  (3) 
liquid  diet;  (4)  suppositories  of  opium  and  belladonna;  (5) 
hot  sitz  baths;  (6)  laxatives;  (7)  irrigation  with  nitrate  of  silver 
solution  1-5000. 

VIL  INJURIES  OF  THE  RECTUM 

Injuries  of  the  rectum,  other  than  those  of  childbirth,  are 
due  to  falls  on  some  sharp  object,  and  are  treated  on  general 
surgical  principles.  A  curious  feature  is  shock  out  of  all 
proportion  to  the  apparent  injury. 

VIII.  ISCHIORECTAL  ABSCESS 

Ischiorectal  abscess  is  due  to  infection  from  the  rectum, 
and  is  a  result  of  periproctitis.  It  tends  to  point  (i)  through 
the  skin  near  the  anus;  (2)  into  the  rectum  between  the  sphinc- 
ters (forming  a  blind  internal  fistula) ;  (3)  occasionally  burrow- 
ing across  the  midline  into  the  opposite  ischiorectal  fossa. 

Symptoms. — (i)  Intense  throbbing  pain  in  the  perineum, 
made  worse  by  sitting,  defecation  or  any  other  exertion;  (2) 
always  constitutional  symptoms  of  sepsis  (fever,  rapid  pulse 
and  leukocytosis). 

Diagnosis.- — (i)  A  bulging  tumor,  to  one  side  of  the  anus, 
brawny,  indurated  and  painful  to  touch;  (2)  redness  of  over- 


PROLAPSE  OF  THE  RECTUM 


369 


lying  skin;  (3)  on  rectal  examination,  a  tender  elastic  swelling 
is  felt  on  the  corresponding  side. 

Treatment. — Early  free  evacuation,  .with  irrigation  and 
drainage.  Spontaneous  rupture  is  to  be  avoided  if  possible, 
due  to  the  danger  of  fistula.  The  pus  is  thick,  very  foul,  and 
contains  bubbles  of  gas.  A  chronic  ischiorectal  abscess  is 
usually  tubercular.  The  swelling  is  hard  and  painless,  and 
then  becomes  softer  as  it  degenerates.  Acute  infection  is 
possible  at  any  time,  and  the  resultant  fistula  is  stubborn  and 
persistent. 

IX.  PROLAPSE  OF  THE  RECTUM 

Prolapse  of  the  rectum,  in  the  adult,  is  seen  most  often  in 
elderly  women,  especially  those  with  perineal  tears,  sphincter 
tears  or  prolapse  of  the  ut- 
erus. It  varies  in  degree  from 
protrusion  of.  the  mucosa  to 
complete  inversion  of  the 
rectum,  with  all  its  coats. 
Protrusion  of  the  mucosa  is 
limited  in  extent,  more  than 
one  inch  being  rarely  seen;  in 
true  prolapse  of  the  rectum 
the  mass  is  sometimes  very 
large.  At  first  the  protru- 
sion is  painless,  but  as  ulcer- 
ation of  the  mucosa  takes 
place,  it  later  becomes  a  very 
painful  affection. 

Diagnosis  is  obvious,  the 
deep  red  protruding  mass 
admitting  of  no  mistake. 

Treatment  is  either  pallia- 
tive or  operative. 

Palliative. — (i)  Reposition,  in  the  knee-chest  posture,  after 
oiling  the  mass;  (2)  strapping  the  buttocks  to  prevent  recur- 
rence, leaving  room  for  defecation;  (3)  a  vulcanite  plug,  held  in 
24 


Fig.  152. — Prolapse  of  the  rectum 
and  uterus.  {Author's  case,  Phila- 
delphia General  Hospital.) 


370  DISEASES    or   THE   RECTUM 

place  by  a  T  bandage,  in  place  of  the  strapping;  (4)  strychnin 
to  the  point  of  tolerance;  (5)  mildly  astringent  enemas,  such 
as  tannic  acid  two  drams,  water  two  pints;  or  zinc  sulphate 
one  dram  to  two  pints  of  water;  or  alum  two  drams  to  one 
pint  of  water. 

Palliative  treatment  offers  no  chance  of  cure  if  there  co-exists 
either  a  complete  tear  or  prolapse  of  the  uterus. 

Operative. — i.  Linear  Cauterization:  Under  general  anes- 
thesia, a  blunt  pointed  Paquelin  or  electric  cautery  at  duU 
red  heat  is  used  to  make  six  or  eight  linear  burns,  along  the 
longitudinal  axis  of  the  bowel.  Only  the  mucosa,  and  never 
the  muscular  coat,  should  be  seared.  The  inflammatory  re- 
action set  up  by  this  often  causes  sufficient  cicatricial  contrac- 
tion to  prevent  a  recurrence. 

2.  The  Moskowitz  operation,  in  which,  by  abdominal  section 
the  rectum  is  suspended,  by  a  series  of  purse-string  sutures 
of  number  i  chromic  catgut  or  fine  linen  thread,  to  the 
back  wall  of  the  uterus,  the  posterior  layers  of  the  broad  liga- 
ments and  the  peritoneum  covering  the  sacrum.  This 
operation  is  most  efficient. 

3,  Afnputation  of  the  prolapsed  portion,  with  suture  of  the 
mucosa  to  the  skin  of  the  anus.  This  has  the  objections  of 
occasional  stricture  and  incontinence,  and  is  indicated  only 
in  irreducible  prolapse. 

An  absolute  essential,  in  both  palliative  and  operative  cases 
is  the  prevention  of  constipation  and  its  consequent  straining, 
as  neglect  of  this  precaution  always  means  recurrence. 

X.  PRURITUS  ANI 

Pruritus  ani  is  a  symptom  of  many  conditions,  chief  among 
which  are:  (i)  Hemorrhoids;  (2)  proctitis;  (3)  worms;  (4) 
pediculi  or  other  results  of  lack  of  cleanliness;  (5)  chronic 
leukorrheal  discharge;  (6)  chronic  constipation;  (7)  diabetes; 
(8)  neurosis.  The  itching  is  often  severe,  and  in  neurotic 
cases  in  pregnancy  intolerable. 

Treatment  is  the  same  as  given  for  pruritus  vulvae,  in  Chapter 


TUMORS   OP   THE   RECTUM  371 

IV,  except  that  the  cause  is  usually  more  easily  found  and 
removed. 

XI.  STRICTURE  OF  THE  RECTUM 

Stricture  of  the  rectum  may  be  due  to:  (i)  Congenital; 
(2)  inflammation;  (3)  cicatrization  of  wounds  or  ulcers; 
(4)  carcinoma;  (5)  syphilis;  (6)  tuberculosis. 

The  bowel  above  the  stricture  is  always  greatly  dilated. 

Symptoms.' — (i)  Pain;  (2)  constipation;  (3)  ribbon-like  stools; 
(4)  discharge  of  mucus,  pus  or  blood;  (5)  rarely  diarrhea  due  to 
enteritis  from  irritation  of  the  retained  feces;  (6)  at  times 
complete  obstruction,  especially  if  malignant. 

Diagnosis  is  made  with  the  finger,  if  the  stricture  is  not  more 
than  four  inches  from  the  anus;  by  proctoscope  if  higher  up. 

Treatment. — (i)  Gradual  dilatation  with  bougies;  (2)  rapid 
avulsion  with  bougies  or  dilator,  never  safe  unless  the  stricture 
can  be  reached  with  the  finger.  The  lower  two-thirds  of  the 
rectum  are  not  covered  by  peritoneum,  the  upper  one-third  is, 
and  the  dividing  line  is  approximately  at  the  reach  of  the 
forefinger;  (3)  incision  of  the  stricture  posteriorly,  with  the 
same  limitations  as  avulsion;  (4)  excision  of  the  stricture,  with 
end-to-end  anastomosis;  (5)  routinely  in  malignant  and  fre- 
quently in  syphilitic  and  tubercular  ones,  inguinal  colostomy. 

XII.  TUMORS  OF  THE  RECTUM 
Tumors  of  the  rectum  are  either  benign  or  malignant. 

Benign  Tumors 

Benign  are  (i)  polyp,  which  is  an  adenoma  with  a  long 
pedicle.  It  is  most  common  in  children  but  is  seen  at  any 
age.  It  is  usually  single,  but  may  be  multiple  and  varies 
in  size  from  a  pea  to  a  large  orange. 

Symptoms. — (i)  Rectal  irritation;  (2)  discharge  of  mucus, 
pus  or  blood;  (3)  frequently  protrusion  of  the  polyp  at 
defecation. 

Treatment  is  removal  by  ligature  or  snare. 


372  DISEASES    or    THE   RECTUM 

2.  Papillomata,  usually  benign  but  occasionally  maKgnant; 
occur  as  cauliflower  masses,  with  the  same  symptoms  as  polyps. 
They  are  removed  with  ligature  or  snare,  and  always  examined 
microscopically. 

Malignant  Tumors 

Cancer  is  usually  tubular  or  cylindrical  celled,  and  begins 
either  as  an  ulcer,  or  as  a  nodule  under  the  mucosa,  with 
secondary  ulceration.  It  frequently  extends  as  a  ring  all 
around  the  rectal  canal.  The  softer  the  cancer,  the  more  malig- 
nant. Metastases  occur  late,  in  the  liver,  lumbar  glands 
and  peritoneum.  The  disease  is  commonest  in  middle  life, 
but  has  been  seen  even  in  childhood. 

Symptoms  are  (i)  Pain;  (2)  tenesmus;  (3)  rectal  irritation; 
(4)  difficulty  in  defecation;  (5)  passage  of  mucus,  pus  or  blood; 
(6)  in  the  late  stages  ribbon  stools,  cachexia  and  more  or  less 
complete  obstruction,  and  sometimes  rectovaginal  fistula. 
Symptoms  are  often  very  slight,  or  absent,  until  the  growth 
has  reached  a  considerable  size. 

Diagnosis  is  made  by  digital  examination,  which  feels  a  soft, 
f ungating,  friable  mass,  bleeding  easily;  or  a  hard  firm  one 
with  ulcerated  surface,  with  everted  edges. 

Through  a  speculum,  the  growth  can  be  seen  and  in  cases 
of  doubt  a  piece  removed  for  microscopic  examination. 

Prognosis  is  bad.  Death  results  in  from  one  to  five  years, 
from  cachexia,  obstruction,  exhaustion  or  hemorrhage. 

Treatment  is  palliative  or  operative. 

Palliative  treatment  is  only  for  those  cases  where  the  growth 
cannot  be  removed,  (i)  Opium  for  pain;  (2)  rectal  irrigation; 
(3)  colostomy,  which  diverts  the  fecal  column  and  retards  the 
progress  of  the  disease;  (4)  both  radium  and  .^•-ray  have  proven 
disappointing  in  rectal  cancer. 

Operative  treatment  consists  in  the  removal  of  the  growth, 
possible  when  it  has  not  involved  the  perirectal  connective 
tissue  or  the  sacrum  or  uterus,  and  there  are  no  demonstrable 
metastases. 


ULCERS    OF    THE    RECTUM  373 

The  primary  mortality  of  operation  is  25  per  cent,  and  of 
the  survivors  only  about  20  per  cent,  are  well  after  three  years. 

Methods  of  Operative  Treatment. — (i)  Vaginal  route,  when 
there  is  a  small  growth  in  the  anterior  rectal  wall;  (2)  anal 
route,  when  the  growth  is  very  low;  (3)  perineal  route,  involving 
splitting  of  the  perineum,  when  the  growth  is  not  more  than 
three  inches  up;  (4)  sacral  route  (Kraske  operation)  for  growths 
just  beyond  the  reach  of  the  finger;  (5)  abdominal  perineal,  in 
very  extensive  involvement. 

The  last  three  operations  are  exceedingly  difficult  and  to  be 
attempted  by  experienced  surgeons  only. 

Sarcoma  has  the  same  symptoms  as  cancer,  is  much  rarer, 
occurs  at  an  earlier  age  and  requires  the  same  treatment. 
It  occurs  as  a  large  fleshy  mass,  without  primary  ulceration. 

XIII.  ULCERS  OF  THE  RECTUM 

Ulcers  of  the  rectum  are  (i)  Simple — due  to  abrasive  wounds, 
foreign  bodies,  etc.;  (2)  tubercular;  (3)  syphilitic;  (4)  malignant; 
(5)  acute  inflammation;  (6)  dysentery;  (7)  typhoid. 

Symptoms  are  (i)  Rectal  irritation;  (2)  pain;  (3)  discharge 
of  pus,  mucus,  or  blood;  (4)  tenesmus;  (5)  usually  constipation, 
due  to  habit  because  of  pain  on  defecation;  (6)  more  rarely 
diarrhea  (dysentery  and  typhoid). 

Diagnosis  is  best  made  through  a  proctoscope. 

Treatment. — (i)  Hot  enemata;  (2)  local  application  of 
nitrate  of  silver  40  grains  to  the  ounce  (8  per  cent.)  through  a 
proctoscope;  (3)  iodoform  suppositories  5  grains  twice  daily, 
especially  in  tubercular  cases  (but  not  if  nitrate  of  silver  has 
been  used  because  of  the  irritating  chemical  reaction);  (4) 
salvarsan  in  syphilis;  (5)  malignant  ulcers  treated  as  described 
under  cancer;  (6)  in  very  stubborn  cases,  temporary  inguinal 
colostomy,  the  artificial  anus  being  closed  after  the  ulcer  has 
healed  (three  to  four  months  usually);  (7)  nearly  all  cases 
require  some  arsenic  and  strychnin  tonic. 


CHAPTER  XX 

ELECTRICITY,  X-RAY,  RADIUM,  MESOTHORIUM 
AND  FINSEN  LIGHT 

ELECTRICITY 

Electricity  at  one  time  exploited  as  a  cure-all  in  gynecology, 
is  very  useful  in  its  very  limited  field.  Many  exaggerated 
claims  were  made,  which  when  exploded  brought  the  entire 
method  of  treatment  into  disrepute.  This  chapter  is  designed 
to  give  an  outline  of  what  it  and  its  allied  methods  of  radiation 
may  reasonably  be  expected  to  accomplish. 

Apparatus  needed  for  gynecologic  treatment  consists  of  the 
following,  as  a  minimum:  (i)  A  source  of  current,  preferably 
an  apparatus  which  is  connected  with  the  street  current  and  by 
rheostats,  stops  it  down  to  a  usable  strength.  A  battery  is 
unreliable  and  the  constant  recharging  a  nuisance. 

2.  A  large  (six  by  eight  inches)  abdominal  pad  electrode, 
covered  by  felt  or  other  moisture  containing  covering.  A 
small  pad  is  not  satisfactory  as  it  does  not  give  proper  contact 
and  does  not  allow  enough  current  to  pass. 

3.  Uterine  electrodes,  built  like  sounds,  and  capable  of  being 
sterilized  by  boiling.  The  best,  and  also  much  the  most 
expensive,  have  platinum  tips.  Copper  and  aluminum  are 
good  substitutes,  but  the  positive  pole  of  the  galvanic  current 
causes  rapid  wear  and  disintegration,  which  is  slowest  in  the 
platinum  and  most  rapid  in  the  copper  tips. 

4.  Vaginal  and  rectal  electrodes,  though  the  vaginal  may  be 
used  as  rectal  ones. 

Properties  of  Galvanic  Current.- — The  positive  pole  (anode) 
is  hemostatic,  promotes  contraction  of  the  uterus,  and  hence 
controls  bleeding;  acts  as  a  cautery  to  the  endometrium  (mild 

374 


ELECTRICITY  .375 

but  often  painful),  and  contracts  down  the  uterine  vessels 
in  the  mucosa. 

The  negative  pole  (cathode)  causes  hyperemia  and  congestion 
of  the  uterus,  promotes  relaxation  of  the  muscle  and  vessels, 
and  allays  pain. 

Properties  of  Faradic  Current.^ — (i)  Primary  faradic,  causes 
contraction  of  the  utecus  and  tends  to  act  as  a  hemostatic. 

2  Secondary  faradic  current  is  used  as  a  sedative  and  allays 
pain. 

The  action  of  the  slow  and  rapid  interruption  is  essentially 
the  same. 

Properties  of  Sinusoidal  Current.^ — This  current  flows  in 
waves,  from  zero  to  maximum,  with  change  of  polarity  at 
each  zero.  It  is  sedative  and  allays  pain  when  used  in  the 
uterus;  in  the  bowel  it  is  an  efficient  treatment  of  obstinate 
constipation. 

In  gynecologic  treatments  the  active  electrode  is  always  the 
internal  one — in  the  uterus  vagina  or  rectum.  The  abdominal 
pad  is  the  passive  electrode,  merely  allowing  the  current  to 
flow  through. 

Indications  for  Intra-uterine  Electrical  Treatment.  I. 
Galvanic  Current. — i.  Positive  pole  to  uterine  sound  in  (i) 
menorrhagia;  (2)  metrorrhagia  (non-malignant);  (3)  inter- 
stitial fibroids  (the  current  will  have  effect  on  the  bleeding, 
but  not  on  the  size  of  the  growth);  (4)  subinvolution  of 
the  uterus;  (5)  chronic  gonorrheal  endocervicitis  (copper 
electrode). 

2.  Negative  Pole  to  Uterine  Sound. — (i)  Infantile  uterus; 
(2)  amenorrhea  from  causes  other  than  pregnancy  or  the 
artificial  and  natural  menopause;  (3)  superinvolution;  (4) 
lactation  atrophy;  (4)  cervical  stenosis  with  dysmenorrhea; 
(5)  chronic  endocervicitis  (nongonorrheal). 

II.  Faradic  current  is  used  in  (i)  subinvolution  of  the 
uterus;  (2)  amenorrhea;  (3)  to  control  muscles  when  weakened 
by  long  disuse  such  as  relaxed  sphincter  ani  or  sphincter 
vesical. 


376  ELECTRICITY,   X-RAY,    RADIUM,    FINSEN    LIGHT 

III.  Sinusoidal  current  is  used  chiefly  in  the  treatment  of 
chronic  constipation.  It  excites  peristalsis  and  is  most  effec- 
tive when  the  lower  bowel  is  filled  with  water  before  the  rectal 
electrode  is  inserted.  In  the  uterus,  its  uses  are  the  same  as 
the  faradic. 

Contra-indication  to  intra-uterine  electrical  treatment  is 
pehdc  inflammation,  unless  acute  symptoms  have  long 
subsided.  Intra-uterine  use  of  the  electric  current  cannot 
be  said  to  be  entirely  safe.  With  proper  aseptic  precautions, 
infection  is  unlikely,  but  severe  pelvic  inflammatory  reaction 
sometimes  follows  its  use,  even  though  all  precautions  have 
been  taken.  When  employed,  it  should  be  with  appreciation 
of  this  possibility. 

Technic  of  Application. — i  The  patient  is  arranged  in  the 
dorsal  position,  and  the  cervix  exposed  through  a  bivalve 
speculum. 

2.  The  abdominal  pad  is  well  soaked  and  applied  so  that 
there  is  firm  broad  contact  to  the  skin. 

3.  The  apparatus  is  examined  to  see  that  it  is  in  working 
order,  and  that  no  current  is  turned  on  until  all  the  electrodes 
are  properly  adjusted. 

4.  The  uterine  electrode  is  sterilized  by  boiling,  or  if  the 
construction  of  its  insulation  does  not  permit  of  this,  soaked 
in  a  solution  of  1-20  carbolic  acid  for  half  an  hour.  It  is 
absolutely  essential  that  the  electrode  be  properly  sterilized. 
Neglect  on  this  score  may  mean  severe  pelvic  infection.  Great 
care  must  also  be  taken  not  to  abrade  the  surface  mucosa,  in 
the  insertion  of  the  electrode. 

5.  When  ready,  the  current  is  turned  on  very  slowly.  If  the 
patient  complains  of  burning  of  the  abdominal  skin,  the  con- 
tact is  poor  and  the  pad  too  dry.  Redness  of  the  abdominal 
skin  is  due  to  too  small  a  pad,  but  blistering  is  very  rare. 

6.  At  first  a  current  of  ten  miUiamperes  is  used,  and  is 
gradually  increased  as  the  patient  can  stand  it.  Much  lower 
amperage  is  used  with  the  positive  than  with  the  negative  pole. 

7.  For   uterine   bleeding  a  galvanic  current  of  10-50  miUi- 


ELECTRICITY  377 

amperes  is  used  for  fifteen  minutes  twice  weekly,  positive  pole 
to  uterine  sound.  For  amenorrhea,  scanty  menses,  infantile 
uterus,  or  stimulation  of  the  sphincter  muscles,  a  galvanic 
current  of  20-70  milliamperes  for  twenty  minutes  three  times 
weekly,  negative  pole  to  uterine  sound.  For  cervical  stenosis, 
use  galvanic  current,  negative  pole  to  uterine  sound,  current 
10-15  milliamperes  for  ten  minutes,  twice  at  a  three-day 
interval,  during  the  week  preceding  the  menses.  For  dysmen- 
orrhea, use  secondary  faradic  current,  for  twenty  minutes  at  a 
time,  every  other  day  for  the  ten  days  preceding  the  period. 

8.  In  all  cases  where  the  intra-uterine  electrode  is  to  be 
used,  pregnancy  must  be  excluded. 

9.  The  length  of  treatment  should  not,  except  for  special 
indications,  exceed  twenty  minutes,  to  avoid  fatigue. 

10.  The  current  is  turned  on  very  slowly,  so  as  to  be  barely 
perceptible,  and  gradually  increased  as  the  patient  becomes 
accustomed  to  it. 

1 1 .  The  intra-uterine  electrode  must  be  constantly  watched, 
as  it  has  a  tendency  to  slip  out  very  easily. 

12.  The  intra-uterine  electrode  should  be  sterilized  directly 
after  use,  and  resterilized  before  being  used  again. 

Cautery. — The  electric  cautery  knife  is  very  useful  for 
excision  of  small  growths,  such  as:  (i)  condylomata;  (2) 
small  cervical  cysts;  (3)  small  cervical  polyps;  (4)  urethral 
caruncle;  (5)  persistent  erosion  of  the  cervix;  (6)  abscess  of 
Skene's  glands.  For  growths  the  knife  is  used;  for  erosion  the 
dome-shaped  spiral;  for  inflammation  of  Skene's  glands  the 
needle.  A  local  anesthetic  is  best  employed;  20  per  cent, 
cocain  applied  to  the  surface,  or  2  per  cent,  cocain  injected 
into  the  base  of  the  growth  to  be  removed.  The  ethyl  chlorid 
spray  should  never  be  used,  as  a  preliminary  to  the  cautery, 
as  it  is  very  inflammable. 

Fulguration  (desiccation)  is  the  process  by  which  small 
growths  or  areas  are  cauterized  by  a  spark  of  enormous  voltage 
and  very  low  amperage.  It  is  most  useful  in  removing  surface 
blemishes,  small  warts  or  pedunculated  growths;  for  cauteriza- 


378  ELECTRICITY,  X-RAY,    RADIUM,    FINSEN    LIGHT 

tion  of  recurrent  surface  carcinoma,  particularly  of  the  mouth 
or  breast  or  in  the  scar  of  the  vaginal  vault;  it  is  the  best 
of  all  methods  for  small  papilloma  of  the  bladder,  used  through 
the  catheter  channel  of  the  cystoscope. 

High  frequency,  in  gynecological  work,  is  used  chiefly  in 
control  of  pelvic  and  sciatic  pain,  to  reduce  high  blood-pressure, 
and  particularly  in  pain  caused  by  pelvic  exudate  persisting 
after  pelvic  peritonitis. 

The  current  has  an  enormous  voltage  but  very  low,  amperage. 

The  main  electrode  is  a  pad  on  which  the  patient  sits;"  the 
other  electrode  is  held  in  the  hands. 

X-RAY 

The  uses  of  the  :v--ray  in  gynecology  are  two-fold;  (i)  for 
diagnostic  purposes;  (2)  for  therapeutic  purposes.  The  rays 
are  capable  of  great  damage,  in  inexpert  hands,  the  greatest 
danger  being  that  of  burns,  which  are  very  slow  to  heal, 
resist  all  applications,  are  very  painful  and  at  times  very 
deep  and  dangerous.  They  are  most  common  in  cases  requir- 
ing prolonged  treatment,  as  for  cancer  and  fibroid;  syphilitic 
patients  are  much  more  likely  to  be  burned,  hence  a  Wasser- 
mann  test  should  always  be  made  as  a  preliminary  to  .^-ray 
treatments,  and  if  positive,  the  treatment  should  be  avoided 
or  at  least  the  time  of  exposure  materially  shortened. 

Diagnostic  use  of  the  x-ray  is  chiefly  for  the  following: 
(i)  Gastro-intestinal  tract,  after  a  bismuth  meal;  (2)  pyelog- 
raphy for  the  pelvis  of  the  kidney  and  ureter,  after  they  have 
been  filled  with  collargol  or  10  per  cent,  thorium  nitrate 
solution;  (3)  the  diagnosis  of  pregnancy,  after  the  sixth  month 
of  gestation.  Prior  to  this  the  fetal  skeleton  casts  no  appreci- 
able shadow,  and  often  even  at  term  the  shadow  is  exceedingly 
faint  and  thin;  (4)  diagnosis  of  osseous  deformity  of  the  pelvis; 
(5)  diagnosis  of  pelvic  tumors;  usually  unsatisfactory,  because 
they  rarely  cast  sufficient  shadow;  (6)  diagnosis  of  foreign 
bodies  left  in  the  abdomen  at  a  previous  operation,  (7)  Diag- 
nosis of  kidney  and  ureteral  stones. 


RADIUM  379 

Uses  of  X-ray  in  Treatment.^ — (i)  Bleeding  from  fibroid 
tumors;  (2)  metrorrhagia  from  myopathic  uteri  or  other  causes; 
(3)  cancer  of  the  uterus;  of  very  doubtful  value;  (4)  superficial 
cancers  of  the  vulva  or  breast;  (5)  lupus  vulvae;  (6)  kraurosis 
vulvae;  (7)  pruritus  vulvae,  (8)  excessive  sexual  hyperesthesia 
(nymphomania);  (9)  for  the  production  of  artificial  sterility, 
by  causing  loss  of  ovarian  function. 

Disadvantages  and  Dangers.^ — (i)  In  fibroid  tumors,  the 
bleeding  may  be  controlled,  and  the  artificial  menopause 
produced,  but  it  has  no  effect  on  subsequent  degeneration  of 
the  growth.  If  malignant  degeneration  has  begun,  the  effect 
of  the  ray  is  often  to  stimulate  the  process  to  furious  activity. 
(2)  Burns  are  always  a  painful  and  distressing  complication 
and  often  very  dangerous  one;  the  more  anemic  the  patient, 
the  more  likely  she  is  to  be  burned;  (3)  the  artificial  meno- 
pause induced  by  the  rays  is  often  complicated  by  very  severe 
nervous  symptoms,  much  more  severe  than  the  surgical 
menopause;  (4)  in  patients  in  the  childbearing  period,  the 
possibility  of  causing  permanent  amenorrhea  and  sterility, 
even  with  short  exposures,  must  be  borne  in  mind;  (5)  in  deep- 
seated  cancer,  the  rays  often  relieve  pain,  but  do  not  influence 
the  process  in  other  ways;  (6)  many  patients  complain  of 
severe  digestive  disturbances,  of  long  duration. 

Treatment  by  a;-ray  is  a  process  involving  considerable 
outlay  in  time,  money  and  patience.  It  is  a  two-edged  sword, 
capable  of  benefit  in  one  direction  often  at  the  expense  of 
harm  in  another,  and  is  not  a  method  adapted  to  amateur 
experimentation,  but  one  to  be  used  only  by  those  thoroughly 
familiar  with  the  apparatus  they  handle. 

RADIUM 

The  physical  properties  are   thus   described  by  Burnam: 
"Radium  is  a  metallic  element  belonging  to  the  strontium- 
barium  group.     It  readily  forms  salts  with  the  mineral  acids 
and  is  the  leading  member  of  the  peculiar  radio-active  group 
of  elements  which  are  characterized  by  atomic  instability. 


380  ELECTRICITY,   X-RAY,    RADIUM,    FINSEX    LIGHT 

"Radium  itself  is  formed  by  atomic  reduction  from  uranium. 
It  loses  a  portion  of  its  atom  to  become  a  gas  called  radium 
emanation,  and  this,  in  turn,  is  the  mother,  grandmother,  etc., 
of  a  series  of  solid  elements.  The  so-called  radium  C,  third 
in  series  from  the  emanation,  is  that  member  of  the  group  which 
particularly  concerns  us,  as  it  is  from  it  that  both  the  beta- 
and  gamma-rays  are  derived.  Radium  emanation  can  be  sepa- 
rated from  radium  as  fast  as  it  is  formed.  A  given  amount  of 
radium  is  capable  of  producing  a  given  amount  of  emanation. 
The  emanation  reaches  a  maximum  and  then  disintegrates 
at  the  same  rate  that  it  is  being  formed.  In  about  four  days  a 
given  amount  is  reduced  to  one-half.  If  radium  or  radium 
emanation  is  sealed  in  a  glass  or  metal  container  it  begins  to 
produce  radium  C.  The  maximum  amount  of  radium  C  is 
obtained  in  a  radium  preparation  so  placed  in  a  glass  tube  in 
thirty  days.  The  maximum  amount  from  emanation  is 
produced  in  three  hours  and  thirty  minutes.  Radium  C 
itself  can  be  isolated,  but  has  such  a  short  life,  only  two  or 
three  hours  total,  that  it  cannot  be  used  effectually  in  practical 
treatment. 

"The  essential  characteristic  of  the  radio-active  substances 
is  the  giving  off  of  in^dsible  rays.  These  rays  must  not  be 
confused  with  the  emanation,  which  is  an  element  just  as 
radium  itself  is.  The  rays  have  been  divided  according  to 
their  physical  characteristics  into  three  kinds:  the  alpha, 
the  beta,  and  the  gamma. 

"The  alpha-ray  is  a  positively  charged  atom  of  helium.  It 
has  a  very  small  power  of  penetration,  being  completely 
stopped  by  a  thin  sheet  of  writing  paper.  It  acts  very  power- 
fully toward  inducing  chemical  change  in  both  inorganic  and 
organic  matter  brought  in  contact  with  it.  The  beta-ray  is  a 
negatively  electric  ion  which  has  about  the  velocity  of  light 
and  will  easily  penetrate  several  centimeters  of  living  tissue. 
It  has  also  a  marked  capacity  for  inducing  chemical  changes  in 
organic  matter  subjected  to  it.  The  gamma-ray  is  not  par- 
ticulate matter,  but  a  \dbration  of  ether  similar  to  ordinary 


RADIUM  381 

light  and  of  x-ray.  It  differs  from  them  in  being  of  much 
shorter  wave  length  and  of  much  greater  penetration.  It  has 
power  also,  but  to  a  lesser  degree  than  the  alpha-  and  beta- 
rays,  to  produce  chemical  change  in  organic  matter  exposed  to 
it.  When  radium  is  enclosed  in  a  glass  tube,  alpha-,  beta-, 
and  gamma-rays  are  produced  within  the  container.  The 
alpha-rays  are  held  in  the  tube,  while  the  beta-  and  gamma- 
rays  penetrate  its  walls,  and  pass  out  into  the  surrounding 
medium  in  radial  lines,  thus  making  a  sphere  of  radiation. 
When  the  .glass  tube  is  further  surrounded  by  2  mm.  of  lead, 
the  hardest  beta-rays  can  no  longer  penetrate  this  envelope. 
It  is  possible,  therefore,  in  medical  treatments  to  use  all  three 
kinds  of  rays  together,  the  beta-  and  gamma-rays  together, 
or  the  gamma-rays  alone.  It  is  impossible  to  use  the  alpha- 
rays  alone,  and  it  is  difficult  to  use  the  beta-rays  alone  in 
anything  except  experimental  work. 

"From  the  above  it  is  evident  that  radium  or  one  of  its 
derivatives  can  be  used  in  two  essentially  different  ways: 
first,  it  can  be  taken  into  the  body  by  mouth,  hypodermically 
or  intravenously  as  any  other  soluble  drug;  second,  it  can  be 
applied  from  either  outside  or  inside  the  body  in  sealed  tubes 
or  other  containers  in  the  same  general  way  that  an  a;-ray 
tube  is  employed." 

As  the  alpha-  and  beta-rays  are  the  ones  that  burn  or  act  as 
unfavorable  stimulants,  they  are  filtered  out  by  encapsulating 
the  radium  in  a  cylinder  of  some  metal,  like  lead,  silver,  brass, 
platinum  or  aluminum.  Of  these  brass  seems  to  cause  the 
smallest  loss  of  the  desirable  gamma-rays,  and  hence  is  to  be 
preferred,  though  the  choice  is  not  a  matter  of  much  moment, 
as  the  difference  is  small. 

Method  of  Use. — A  minimum  amount  of  50-100  mg.  of 
radium,  in  a  glass  tube,  is  enclosed  in  a  brass  filter  and  then  in  a 
finger-cot,  and  is  inserted  in  the  uterine  canal  and  held  in  place 
by  a  temporary  suture  through  the  cervix,  which  grips  the 
end  of  the  finger-cot  as  well.  It  is  left  in  place  from  three 
hours  to  five  days,  according  to  the  judgment  of  the  operator. 


382  ELECTRICITY,   X-RAY,    RADIUM,    FINSEN    LIGHT 

eighteen  hours  being  the  average.  About  two  weeks  is  allowed 
between  treatments.  The  gamma-rays  penetrate  and  kill 
cancer  cells  to  a  depth  of  3-4  cm.,  and  beyond  this  point 
have  an  inhibiting  action  on  their  growth. 

The  gamma-rays  and  the  hard  beta-rays  have  a  selective 
action  on  cancer  cells,  killing  them  without  damage  to  the  nor- 
mal cells  surrounding  the  area  of  malignancy. 

Effect  of  radium  depends  upon:  (i)  The  age  of  the  growth; 
(2)  the  amount  of  radium  used;  (3)  the  amount  of  filtration;  (4) 
the  length  of  exposure;  (5)  the  distance  or  depth  of  the  growth; 
(6)  the  length  of  exposure  and  (7)  the  frequency  of  treatment. 

Favorable  Effects. — (i)  In  metrorrhagia  from  a  myopathic 
uterus,  100  per  cent,  of  cures  can  be  expected;  (2)  in  cancer 
of  the  cervix  the  fetid  discharge  and  bleeding  cease;  (3)  the 
growth  diminishes  in  size  or  even  disappears;  (4)  pain  is 
promptly  reheved;  (5)  inoperable  cases  may  be  made  operable; 
(6)  the  most  favorable  results  are  obtained  in  recurrence  in 
the  vaginal  scar  after  hysterectomy;  because  the  younger  the 
cancer  cell,  the  more  destructive  to  it  is  radium. 

Dangers  and  Disadvantages. — (i)  Overdosage,  or  too  long 
exposure  may  result  in  excessive  destruction  of  tissue;  (2) 
under  dosage  or  too  short  exposure,  may  stimulate  the  malig- 
nant growth  to  activity;  (3)  if  pelvic  infection  is  present,  active 
pelvic  peritonitis  may  result;  (4)  if  cancer  has  involved  the 
bladder  or  rectal  wall,  fistulae  are  very  likely  to  result;  (5) 
hysterectomy  too  soon  after  radium  treatment  is  very  likely 
to  be  followed  by  fatal  postoperative  sepsis;  three  weeks  at 
least  should  elapse;  (6)  after  treatment  prior  to  hysterectomy, 
the  parametrium  is  sclerosed  and  infiltrated,  and  this  adds 
materially  to  the  difi&culty  of  the  operation. 

Reaction  from  use  of  radium  is  small  as  a  rule,  but  may  be 
evident  as:  (i)  Headache;  (2)  abdominal  pain;  (3)  pain  in 
bladder;  (4)  diarrhea;  (5)  fever  or  moderate  degree  (101-102); 
(6)  occasionally  acute  nephritis. 

These  reactions  are  most  common  in  elderly  patients  and  in 
those  with  severe  anemia. 


FINSEN    LIGHT  383 

The  expense  of  a  quantity  of  radium  sufficient  to  carry  out 
treatment  is  so  great  that  it  must  necessarily  remain  a  method 
for  large  institutions  rather  than  the  individual  physician. 

MESOTHORIUM 

Mesothorium  is  like  radium  in  its  physical  properties  and 
effects,  and  what  has  been  said  about  radium  applies  to  meso- 
thorium as  well.  While  radium  continues  giving  out  its 
emanations  in  undiminished  volume  for  many  centuries, 
mesothorium  is  exhausted  and  inert  in  about  twelve  years. 

FINSEN  LIGHT 

Finsen  light  therapy  is  of  use  only  in  lupus  vulvae,  and  does 
not  even  there  give  results  comparable  to  the  a;-ray,  hence 
its  use  in  gynecology  is  practically  nil. 


CHAPTER  XXI 

ENDOCRIN  GLANDS  AND  THEIR  EXTRACTS 
IN  GYNECOLOGY 

The  beginning  of  organotherapy  was  Brown-Sequard's 
experiments,  in  1889,  with  injections  of  testicular  juice. 
Since  then  a  mass  of  Hterature  and  experimental  work  has 
been  accumulating,  though  the  surface  has  hardly  as  yet  been 
scratched.  For  much  of  the  material  from  which  this  chapter 
is  compiled,  the  author  is  indebted  to  the  articles  by  Hugo 
Ehrenfest  in  Crossen's  gynecology  and  W.  P.  Graves. 

The  term  ductless  gland  (endocrin)  is  applied  to  a  number  of 
special  glands  or  organs,  producing  biologic  substances  which 
when  absorbed  into  the  blood  in  normal  amounts,  maintain  the 
organism  at  par,  and  exert  definite  effects  on  distant  organs. 
They  are:  (i)  Thyroid;  (2)  parathyroid;  (3)  thymus;  (4) 
suprarenal;  (5)  pituitary  gland  or  hypophysis  cerebri;  (6) 
pineal  gland  or  epiphysis  cerebri;  these  the  true  ductless 
glands;  (7)  pancreas;  (8)  ovary;  (9)  testicle;  (10)  mammary 
gland;  these  having  external  as  well  as  internal  secretory 
function;  (11)  the  corpus  luteum;  (12)  the  placenta;  from 
which  animal  extracts  for  therapeutic  purposes  are  made  and 
hence  deserve  inclusion  in  the  list. 

The  sex  glands  (testicle  and  ovary)  are  largely  responsible  for 
the  development  of  male  and  female  characteristics  in  the 
individual  and  their  early  removal  exerts  a  profound  influence 
on  the  development  of  these  characteristics. 

Increased  activity  of  a  gland  is  hyp 67- function;  diminished 
activity  is  hypofunction. 

The  active  materials  of  the  endocrin  glands  are  of  a  simpler 
chemical  constitution  than  enzymes,  and  are  not  rendered 

384 


THYROID    GLAND  385 

inert  even  by  prolonged  boiling,  and  are  known  by  the  generic 
term  of  "hormones." 

Interglandular  Relations. — While  it  is  known  that  the  action 
of  most  of  the  ductless  glands  is  correlated  and  often  recip- 
rocal, exact  knowledge  is  wanting.  Hypofunction  in  one 
gland  is  supposed  to  induce  hyperfunction  in  another  (as  in 
the  ovary  and  thyroid),  if  under  normal  conditions  they  are 
antagonistic.  Perfect  harmony  and  balance  between  all  the 
endocrin  glands  results  in  normal  development;  abnormal 
development  is  often  a  result  of  disturbed  balance.  Our 
present  knowledge  is  too  meager  to  formulate  deiinite  state- 
ments as  to  the  mechanism. 

In  experimental  work,  hormones  act  differently  on  different 
species  of  animals;  deductions  drawn  from  animal  experimenta- 
tion and  applied  to  the  human  being  are  often  absolutely  in- 
correct. Of  all  the  active  principles,  as  yet  only  adrenalin 
has  been  isolated  in  pure  form. 

I.  The  Thyroid. — At  puberty  the  thyroid  often  takes  on 
considerable  enlargement,  which  is  much  more  marked  in 
girls  than  in  boys.  The  nervous  disturbances  of  puberty  are 
ascribed  to  hypersecretion  of  the  thyroid.  The  thyroid  and 
ovary  are  antagonistic,  and  women  with  diseased  thyroids 
usually  have  menstrual  disorders;  also  patients  in  whom  a 
goiter  has  been  too  completely  removed  often  develop  menor- 
rhagia,  which  yields  to  the  administration  of  thyroid  extract. 

The  thyroid  frequently  swells  in  pregnancy,  and  while  the 
enlargement  is  usually  moderate,  it  is  sometimes  very  great. 
It  disappears,  as  a  rule,  during  the  period  of  lactation.  Ex- 
ophthalmic goiter  is  eight  times  as  common  in  women  as  in  men. 
It  is  frequently  a  complication  of  pregnancy,  which  influences 
the  goiter  unfavorably.  When  associated  with  pelvic  con- 
ditions requiring  operation,  it  adds  appreciably  to  the  risk. 
Cretinism  (myxedema)  is  due  to  absence  or  early  atrophy  of 
the  thyroid,  and  the-  adult  type  is  much  more  frequent  in 
women  than  in  men;  in  these  cases  infantile  genitalia  and 
sterility  are  the  rule. 


386  ENDOCRIN    GLANDS    AND    THEIR    EXTRACTS 

2.  Parathyroid s.^ — When  the  parathyroids  are  removed,  in 
animals,  death  follows  from  acute  tetany;  this  tetany  can  be 
controlled  by  administration  of  parathyroid  extract.  Based 
upon  this,  the  extract  has  been  recommended  in  eclampsia  in 
the  human  being,   but  clinically  the  results  have  been  nil. 

3.  The  Thymus.^ — The  thymus,  until  puberty,  has  an 
unquestionable  relation  to  the  development  of  the  sexual 
organs.  At  puberty  there  is  a  marked  involution  in  the  gland. 
If  the  genitals  are  infantile,  involution  takes  place  later  than 
normal.  No  definite  results,  of  value  from  a  therapeutic 
standpoint,   have  yet  been   attained  in   experimental   work. 

4.  Suprarenals  (Adrenals).- — Animals  with  marked  sexual 
powers  are  possessed  of  markedly  developed  adrenals  also. 
Negroes  show  this  more  markedly  than  the  white  race.  In 
individuals  with  hypoplastic  genitalia,  a  diminution  of  the 
adrenals  has  been  noted.  Hypernephroma  in  children  also 
produces  precocious  sexual  development.  Castration  is  fol- 
lowed by  development  of  the  adrenals,  possibly  as  a  compensa- 
tory process  for  the  loss  of  ovarian  secretion. 

Individuals  with  Addison's  disease  frequently  have  hypo- 
plastic genitalia,  amenorrhea,  and  are  sterile.  If  they  become 
pregnant,  the  pregnancy  has  a  deleterious  effect  upon  the 
disease  and  abortion  is  common. 

Adrenalin  is  the  only  active  principle  of  any  of  the  ductless 
glands  which  has  so  far  been  isolated  in  pure  form. 

5.  Pituitary  (Hypophysis  Cerebri). — This  gland  has  a  marked 
relation  to  the  sexual  organs.  During  pregnancy  it  is  hyper- 
trophied,  and  to  this  is  ascribed  the  acromegalic  changes  often 
seen  in  the  faces  of  pregnant  women.  The  hypertrophy 
is  confined  to  the  anterior  lobe,  and  does  not  return  to  normal 
for  several  years  after  gestation. 

Removal  of  the  anterior  lobe  causes  in  animals  marked  obes- 
ity, the  genitalia  of  adult  animals  atrophy  while  those  of  young 
ones  do  not  develop.  The  genital  changes  were  much  more 
marked  in  young  than  in  adult  animals.  If  the  gland  was 
removed  in  pregnant  animals,  they  invariably  aborted.     If 


OVARY  387 

hyperfunction  of  the  pituitary  occurs  before  puberty,  gigantism 
results;  after  puberty,  acromegaly. 

Hypof unction  before  puberty  results  in  dwarfism;  after 
puberty,  in  obesity  associated  with  genital  atrophy  (dystrophia 
adiposogenitalis) . 

Organotherapy. — Preparations  of  the  pituitary  are:  (i) 
Extracts  of  the  whole  gland,  in  powder  or  tablet  form;  (2) 
extract  of  the  anterior  lobe  in  tablet  or  as  a  liquid  extract  in 
ampules;  (3)  extract  of  the  posterior  lobe  in  tablet  or  as  a 
liquid  extract  in  ampules. 

Extract  of  the  whole  gland  is  used  in  obesity  with  genital 
atrophy,  as  is  also  exjtract  of  the  anterior  lobe.  The  anterior 
lobe  limits  carbohydrate  absorption.  It  has  been  used,  but 
with  poor  success,  as  a  galactagogue. 

Extract  of  the  posterior  lobe  is  a  very  active  and  powerful 
stimulant  to  unstriped  muscle,  hence  stimulates  uterine 
contraction  in  labor.  It  is  of  great  value  in  controlling  disten- 
tion after  abdominal  section,  and  to  stimulate  the  bladder  in 
postoperative  retention  of  urine.  It  raises  blood-pressure, 
and  hence  combats  postoperative  shock.  It  controls  bleeding 
in  cases  of  uterine  inertia  and  particularly  in  menorrhagia  of 
youth.     It  is  an  active  heart  stimulant. 

6.  Pineal  Gland  (Epiphysis  Cerebri)  .^ — ^Hypof unction  of 
this  gland  in  early  childhood,  produces  marked  sexual  pre- 
cocity; its  hyperfunction  causes  marked  obesity. 

7.  Pancreas.^ — No  definite  relation  between  the  pancreas 
and  genitalia  has  yet  been  established. 

True  diabetes,  induced  in  animals  after  conception,  causes 
abortion.  In  human  beings,  pregnancy  influences  diabetes 
unfavorably,  except  under  careful  and  rigid  dietary  control, 
and  abortion  is  exceedingly  common. 

8.  Ovary.^ — The  ovary  is  a  true  organ  of  internal  secre- 
tion as  is  proven  by  results  from  transplantation  of  ovarian 
tissue.  Castration  before  puberty  causes  failure  of  genital 
development,  while  after  puberty  it  causes  atrophy  similar  to 
the  menopause.     Injection  of  ovarian  substance  relieves  the 


388  ENDOCRIN    GLANDS    AND   THEIR   EXTRACTS 

unpleasant  symptoms  of  this  condition,  and  if  injected  in 
virgin  animals  creates  hyperemia  of  the  internal  and  external 
genitalia. 

From  what  part  of  the  ovary  this  secretion  is  manufactured 
is  not  known.  But  there  is  evidence  to  support  the  following 
conclusions:  (i)  The  follicle  apparatus  controls  the  growth  and 
nutrition  of  the  genitalia.  (2)  The  corpus  luteum  controls 
menstruation,  and  prepares  and  sensitizes  the  endometrium 
for  the  reception  of  the  impregnated  ovum.  The  destruction 
of  the  corpus  luteum  in  animals  results  in  abortion.  (3)  The 
part  played  by  the  interstitial  gland  is  a  matter  of  conjecture, 
but  it  is  supposed  that  it  shares  with  the  follicle  apparatus 
some  power  of  control  over  development  of  the  genitalia. 

Hypofunction  of  the  ovary  causes."  (i)  Lack  of  development; 
(2)  because  of  the  associated  development  of  the  anterior 
lobe  of  the  hypophysis,  adiposis  and  genital  atrophy;  (3) 
infantilism;  (4)  atrophy  of  the  uterus  and  external  genitalia; 
(5)  fuctional  amenorrhea;  (6)  after  castration,  and  at  normal 
menopause,  hot  flashes,  dizziness,  sweats  and  other  vasomotor 
disturbances. 

Hyperfuncton  of  the  ovary  is  not  as  well  understood.  It  is 
supposed  to  cause  menorrhagia;  premature  sexual  development; 
overfertility;  delay  in  coagulation  time  of  the  menstrual  blood. 

All  these  are  based  upon  theoretical  grounds  and  are  not 
well  founded  on  scientific  proven  facts. 

Organotherapy. — Ovarian  extract  is  prepared  as:  (i)  Powder 
or  tablets  of  Ovarian  substance;  (2)  powder  or  tablets  of  corpus 
luteum;  (3)  hypodermic  extract  of  corpus  luteum;  (4)  hypo- 
dermic extract  of  whole  ovarian  substance;  (5)  hypodermic 
extract  of  ovarian  substance  with  the  corpus  luteum  removed 
(called  ovarian  residue). 

These  preparations  are  from  the  pig,  cow,  or  sheep.  It  is 
claimed  that  the  corpus  luteum  of  the  pig  approximates  most 
closely,  in  the  character  and  number  of  its  lutein  cells,  that 
of  the  human  being.  Extracts  of  human  corpus  luteum, 
prepared    from    material    secured    during    operations     are 


MAMMARY    GLAND  389 

more  active  than  those  of  the  lower  animals,  but  the  supply 
is  too  limited  and  uncertain  ever  to  make  the  human  extract 
of  practical  value. 

Because  the  corpus  luteum  in  pregnancy  is  supposed  to  be 
more  stable,  ovarian  extracts  are  best  made  from  ovaries  of 
pregnant  animals. 

Uses: — (i)  Functional  deficiency  or  absence  of  ovarian 
internal  secretion,  seen  at  the  surgical  or  natural  menopause. 
(2)  Young  women  with  fuctional  amenorrhea  or  scanty  men- 
struation. (3)  Cases  of  pruritus,  kraurosis  or  other  vulvar 
affections  in  elderly  women,  dependent  upon  inadequate 
circulation.  (4)  Repeated  abortions  without  demonstrable 
cause,  but  due  presumably  to  the  absorption  or  blighting  of 
the  corpus  luteum.     (5)  The  control  of  the  nausea  of  pregnancy. 

The  use  of  ovarian  extracts  is  not  dangerous.  The  only 
toxic  effect  of  mouth  administration  is  nausea.  Hypodermic 
extracts  cause,  rarely,  urticaria  and,  still  more  rarely,  mild 
anaphylaxis,  shown  usually  by  depression  of  blood-pressure 
and  headache.  This  is  more  common  in  corpus  luteum  ex- 
tracts than  in  those  of  the  whole  ovary. 

The  dosage  of  the  powder  or  tablets  is  five  grains  four  times 
daily;  one  grain  representing  six  or  seven  grains  of  the  fresh 
substance. 

For  hypodermic  use,  the  dose  is  one  ampule  (i  mil  represent- 
ing 20  mg.  of  the  fresh  substance)  daily  in  series  of  twenty- 
four  doses,  with  an  interval  of  six  to  eight  weeks  between 
series,  as  the  effect  is  often  cumulative. 

9.  The  mammary  gland  has  a  definite,  but  little  understood 
relation  to  the  genitalia.  At  puberty  the  breasts  develop; 
at  each  menstrual  period,  they  enlarge  in  many  cases;  in  preg- 
nancy they  undergo  marked  hypertrophy  and  after  the  meno- 
pause they  atrophy. 

Hypoplasia  of  the  breasts  following  castration  can  often  be 
prevented  by  ovarian  transplantation. 

The  nature  of  the  hormone  controlling  the  development  and 
function  of  the  breast  is  not  known. 


390  ENDOCRTN    GLANDS    AND    THEIR   EXTRACTS 

Extract  of  mammary  gland  is  used  in  the  control  of  func- 
tional menorrhagia  or  metrorrhagia,  due  to  adnexal  disease, 
fibroid  tumors  and  metrorrhagia  myopathica,  but  the  results 
have  not  been  brilliant,  and  the  practical  use  is  small. 

ID.  The  placenta  is  not  an  organ  of  internal  secretion,  but 
its  extracts  have  certain  influence  of  the  maternal  organism. 
The  substance  extracted  from  the  placenta  appears  to  be  iden- 
tical with  a  similar  substance  from  corpus  luteum.  In  animals, 
placental  extract  induces  hyperplasia  of  the  uterus  and  breasts 
and  acts  as  a  galactogogue. 

In  human  beings  extracts  of  the  placenta  of  lower  animals 
do  not  have  routinely  a  similar  effect,  though  such  might  and 
probably  would  be  the  case  were  the  material  of  human  origin. 
It  was,  in  the  middle  ages,  a  common  practice  for  midwives 
and  physicians  to  feed  finely  chopped  placenta  to  recently 
delivered  women,  as  a  galactogogue. 

Gynecological  anomalies  due  to  disturbed  function  of  the 
endocrin  glands  are:  (i)  Failure  of  development  of  the  genitalia; 
(2)  infantilism  (imperfect  development) ;  (3)  delayed  puberty; 
(4)  precocious  puberty;  (5)  menstrual  abnormalities  (oligo- 
menorrhea and  menorrhagia);  (6)  uterine  atrophy;  (7)  metror- 
rhagia; (8)  obesity  with  genital  hypoplasia  and  steriHty. 

Methods  of  Administration. — Mouth  administration  of 
extracts  in  powder  or  tablet  form  has  been,  till  lately,  the 
method  employed.  The  average  dose  is  5  grains  four  times 
daily.  The  method  has  certain  disadvantages;  (i)  Gastric 
disturbance  (nausea)  necessitating  discontinuance  of  the  drug; 
(2)  the  substance  does  not  keep  well  and  oxidizes  easily  on 
exposure  to  the  air;  (3)  most  important  of  all,  the  substance 
does  not  enter  directly  into  the  circulation,  but  is  changed  and 
in  many  cases  destroyed  by  digestion. 

Hypodermic  intramuscular  administration  is  deservedly 
increasing  in  popularity  and  is  much  the  better  form  of  admin- 
istration. The  average  dose  is  one  ampule  daily.  The  best 
syringe  is  glass,  boiled  and  cooled  before  the  substance  is 
drawn  into  it.     Alcohol  is  not  a  good  sterihzing  medium  and 


METHODS    OF   ADMINISTRATION  391 

inhibits  the  activity  of  the  extract.  Injections  are  given  deep 
intramusctdarly  and  never  subcutaneously.  Abscess,  with  proper 
technic,  need  not  be  feared,  but  local  hyperemia  is  the  rule 
for  a  few  hours.  If  the  site  of  injection  is  painful,  a  dressing 
of  alcohol  and  water,  equal  parts,  promptly  relieves  the 
discomfort.  The  site  of  injection  should  be  massaged  for  a 
minute  after  the  injection. 

Reaction  after  hypodermic  administration  is  uncommon. 
Urticaria  sometimes  occurs  in  sensitive  individuals  as  in 
any  animal  serum.  Anaphylaxis  is  very  rare,  and  mild  when 
it  does  occur,  and  is  shown  by  headache  and  lowered  blood 
pressure. 

Pluriglandular  therapy,  or  administration  of  extracts  of 
several  glands  (thyroid,  pituitary  and  ovary)  is  useful  in  all 
cases  where  ovarian  extract  or  corpus  luteum  is  indicated, 
except  castration.  It  is  most  useful  in  functional  amenorrhea 
or  oligomenorrhea,  and  especially  in  cases  with  marked  neuro- 
sis or  neurasthenia  and  obesity.  In  disturbances  of  the 
menopause,  to  be  effective,  it  must  be  given  with  corpus 
luteum  extract,  but  is  no  more  effective  in  these  cases  than  the 
corpus  luteum  extract  alone. 


CHAPTER  XXII 
GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

The  author  has  attempted  to  described  in  this  chapter  a 
technic  that  has  given  him  good  results,  and  has  emphasized 
certain  points  of  importance  which  the  student  is  liable  to  over- 
look. The  chapter  is  designed  to  furnish  the  student  a  ground- 
work from  which  to  develop  a  technic  of  his  own. 

The  equipment  of  a  hospital  operating  room  is  designedly 
omitted.  Hospitals  are  so  well  standardized  that  such  a 
description  is  unnecessary  in  a  book  of  this  character. 

I.  Preparation  of  Patient  for  Abdominal  Section.^ — Day 
before  Operation. — -Urine  examination,  blood  count  and  full 
bath.  4  P.M.  Scrub  abdomen  and  upper  one-third  of  thighs 
for  ten  minutes  by  the  clock,  using  soft  bristle  brush  (face 
brush)  or  gauze;  after  first  two  minutes  shave  completely. 
Rinse  off  soapsuds,  and  scrub  for  one  minute  in  alcohol  (95 
per  cent.)  using  fresh  brush,  rinse  off  again  with  sterile  water, 
dry  with  sterile  towel,  and  apply  dry  sterile  gauze  dressing 
with  binder,  covering  abdomen  and  upper  one-third  of  thighs, 
and  fastened  down  by  spica  bandage  so  that  it  cannot  ride  up 
and  expose  the  abdominal  skin. 

7  P.M.  She  is  given  a  light  supper. 

9  P.M.  Give  one  ounce  of  magnesium  sulphate,  or,  if  this 
is  objectionable  to  her,  eight  ounces  of  flat  magnesium  citrate 
(without  the  gas). 

If  she  is  nervous  or  sleepless,  ten  grains  of  veronal  or 
trional  are  given. 

Day  of  Operation. — Early  in  morning,  cup  of  beef  tea,  no 
other  breakfast.  Two  hours  before  operation  repeat  scrubbing 
of  day  before,  except  that  shaving  is  omitted,  and  after  alcohol, 

392 


PREPARATION    FOR  VAGINAL    OPERATION  393 

apply  dressing  moist  with  i  per  cent,  formalin  solution,  held  in 
place  by  same  kind  of  binder.  An  hour  and  a  half  before 
operation  cleanse  lower  bowel  by  simple  enemas  so  that  last 
enema  returns  clear. 

Three-quarters  of  an  hour  before  operation  give  hypodermic 
of  morphin  sulphate  gr.  )-^,  atropin  sulphate  gr.  3''150- 
Catheterize  just  before  etherization,  and  never  trust  to  voiding. 

The  nurse  who  does  the  scrubbing  must  prepare  her  hands  and 
wear  sterile  gown  and  sterile  gloves,  as  for  an  operation.  No 
preparation  on  the  table  except  wiping  the  abdomen  with 
70  per  cent,  alcohol,  to  take  care  of  the  surface  infection  due  to 
perspiring  under  the  dressing. 

In  all  abdominal  sections,  the  abdomen  is  covered  with 
rubber  dam,  through  which  the  incision  is  made.  Before  the 
peritoneum  is  opened,  the  edges  of  the  rubber  dam  are  sewed 
into  the  wound,  so  that  the  skin  is  completely  covered.  In  a 
wound  of  ordinary  length,  one  stitch  to  each  side  is  sufficient. 
The  principle  involved  is  the  same  that  demands  the  wearing 
of  rubber  gloves;  as  the  human  skin  cannot  be  sterilized,  it 
should  be  covered  as  much  as  possible. 

In  emergency  cases,  where  time  is  limited,  or  where  the 
abdomen  is  very  sensitive,  cover  abdomen,  after  shaving,  with 
gauze  dripping  wet  with  tincture  of  green  soap,  and  cover 
with  binder;  after  two  hours,  take  off  gauze,  wipe  off  abdomen 
with  alcohol  95  per  cent.,  and  apply  wet  dressing  of  i  per  cent, 
formalin  for  two  hours,  held  on  by  binder. 

II.  Preparation  for  any  Vaginal  Operation.  Day  before 
Operation. — 4  p.m.  Shave  pubes  completely.  9  p.m.  Mag- 
nesium sulphate  3^^  ounce. 

Day  of  Operation. — Early  in  morning,  cup  of  beef  tea,  no 
other  breakfast.  Clear  lower  bowel  out  thoroughly  by  repeated 
enemas,  so  that  last  enema  is  given  at  least  two  hours  before 
operation.  Continue  enemas  until  the  water  returns  clear. 
Two  hours  before  operation  give  paregoric  one  and  one-half 
teaspoonfuls.     Catheterize  just  before  etherization. 

Do  not  give  any  hypodermic  of  morphin  and  atropin.     The 


394     GENERAL  TECHNIC  OP  GYNECOLOGIC  SURGERY 

paregoric  takes  its  place.  Paregoric  inhibits  peristalsis  much 
better  than  morphin,  and  makes  less  likely  the  annoying 
accident  of  a  bowel  movement  during  the  operation.  Should 
the  patient  have  much  mucus  in  the  throat  during  anesthesia, 
atropin  may  be  given  hypodermically,  without  morphin. 

Local  preparation  is  done  on  the  table,  and  consists  of  careful 
scrubbing  of  the  external  genitalia  with  tincture  of  green 
soap  and  hot  water,  using  cotton  pledgets,  and  not  gauze. 
Then  the  vagina  is  cleansed  with  the  same  solution  followed 
by  a  douche  of  lysol  (i  dram  to  2  pints)  solution,  and 
followed  in  turn  by  70  per  cent,  alcohol.  In  cases  with  intact 
hymen,  the  internal  scrubbing  is  of  course  omitted  and  the 
douche  alone  used. 

III.  Preparations  for  Operations  in  Private  Houses. — It  is 
perfectly  feasible  to  arrange  private  houses  for  operations  so 
that  the  lack  of  hospital  facilities  need  not  seriously  be  felt. 
An  abdominal  operation  is,  of  course,  more  easily  done  and  the 
patient  more  easily  cared  for  in  a  hospital  than  at  the  patient's 
home,  but  even  this  type  of  operation  can  adequately  be 
cared  for  at  home,  provided  the  preparation  is  sufficiently  well 
made.  Ordinary  operations,  especially  plastics  for  the  repair 
of  the  injuries  of  childbirth,  are  satisfactorily  done  in  the 
patient's  home.  A  trained  nurse,  or  one  at  least  accustomed 
to  the  care  of  surgical  cases  and  with  a  working  knowledge  of 
asepsis,  is  most  desirable,  but  not  indispensable,  provided  the 
physician  is  willing  to  give  minute  instructions  as  to  the  care 
required  and  to  attend  to  such  details  as  catheterization  himself. 

The  Choice  of  a  Room. — If  possible,  the  room  should  be  one 
adjoining  the  patient's  bedroom,  and  preferably  not  the  pa- 
tient's own  room.  The  patient  is  thus  spared  the  sight  of  the 
necessary  preparation.  The  paramount  question  is  one 
of  light,  and  the  operating  table  should  be  so  placed  as  to  get 
the  maximum  amount,  hence,  near  the  window.  The  window 
can  be  screened  against  outside  observation  by  covering  it  with 
a  single  piece  of  gauze  or  by  pinning  together  the  curtains, 
provided  they  are  of  a  material  which  will  transmit  the  light 


OPERATIONS   IN   PRIVATE   HOUSES 


395 


without  too  much  diminution,  or  even  by  soaping  or  white- 
washing the  panes  of  glass.  Except  for  an  abdominal  opera- 
tion it  is  not  necessary  to  strip  the  room  or  take  up  the  carpets 
or  rugs.  The  floor  can  be  protected  by  newspapers,  thickly 
laid,  and  over  these  a  sheet,  wrung  out  of  a  i-iooo  bichlorid 
solution,  should  be  spread  and  should  be  damp  when  the 
operation  is  begun.  Any  unnecessary  hangings  ought  to  be 
removed  and  the  furniture  moved  to  a  part  of  the  room  where 
it  will  be  out  of  the  way  and  covered  with  sheets.  The  walls 
in  the  immediate  vicinity  of  the  operating  table  should  be 


Fig.  153. — A  room  in  a  private  home  arranged  for  operation.  In  the 
center  is  the  kitchen  table  with  a  Kelly  pad  made  of  newspapers,  and  cover- 
ed with  a  sheet.  To  the  right  is  a  table  carrying  a  pile  of  sterile  towels, 
a  jar  of  pledgets,  a  bottle  of  sutures,  and  the  instrument  pan.  On  the 
left  is  a  sewing-table  with  one  bowl  of  i  per  cent,  lysol,  one  bowl  of  i :  1000 
bichlorid,  each  with  pledgets,  a  pitcher  of  fresh  hot  lysol  solution,  and  a 
saucer  containing  alcohol  for  the  knives.      {De  Lee.) 

protected  by  sheets  held  up  by  the  glass-headed  pins  known 
as  Moore's  push-pins,  and  not  by  tacks.  The  pins  leave  no 
scars,  as  tacks  do,  especially  in  wall-paper  and  plaster.   ■ 

The  Operating,  Table. — This  should  preferably  be  one  of  the 
models  of  portable,  collapsible  operating  tables,  but  this 
is  by  no  means  a  necessity.  A  kitchen  table  with  sufficient 
strength  of  legs  answers  every  purpose.  If  this  is  used,  the 
top  must  be  thoroughly  scrubbed  and  then  thickly  padded,  as 
the  thinly  padded  table  is  a  prolific  cause  of  backache  after 
operations.     In  many  operations,  notably  perineal  operations, 


396 


GENERAL   TECHNIC    OF    GYNECOLOGIC    SURGERY 


a  pad  can  be  improvised  by  rolling  up  rubber  sheeting  at 
the  sides  and  back,  or  even  newspapers  covered  by  towels 
or  sheets.  A  Kelly  pad  is  not  a  desirable  feature.  It  is  too 
easily  infected  and  too  hard  to  clean.  The  special  tables  are 
provided  with  stirrups  and  leg-holders  for  the  lithotomy  posi- 
tion, when  this  position  is  desired.  The  kitchen  table  can  be 
equally  well  equipped  with  either  Edebohls'  portable  leg  sup- 
ports, which  clamp  on  the  edge  of  the  table,  or,  much  better. 


Fig.    154. — Diagram  of  room  in  private  house  arranged  for  operation. 

by  a  rolled  sheet  tied  about  one  knee,  passed  back  over  one 
shoulder  and  out  under  the  other  (so  that  pressure  does  not 
come  altogether  on  the  patient's  neck)  and  fastened  above  the 
other  knee.  The  knots  should  be  on  the  outside  of  the  leg. 
This  makes  the  best  leg-holder  I  know.  If  the  Edebohls' 
supports  are  used,  it  will  be  found  necessary  to  tighten  the 
screws  with  a  wrench  (no  one's  fingers  are  strong  enough), 
for,  if  the  patient  should  strain,  the  leverage  is  enormous. 


OPERATIONS   IN   PRIVATE    HOUSES 


397 


If  a  chair  or  stool  is  needed,  a  piano-stool  draped  with  a  sheet 
is  most  satisfactory,  but  a  plain  chair  (not  too  low)  will  answer. 
The  end  of  the  Kelly  pad,  or  its  substitute,  should  drain  into  a 
bucket  or  slop-jar  which  has  been  well  scalded  out. 

The  special  operating  tables  have  apparatus  for  the  Trendel- 
enburg position;  the  kitchen  table  can  be  equally  well  equipped 


Pig.  155. — Lithotomy  position  with  limbs  supported  by  a  sheet- 
sling.      {De  Lee.) 

by  raising  the  two  legs  on  blocks  or  bricks,  or  even,  if  the 
extreme  position  is  desired,  on  the  seats  of  two  chairs.  The 
whole  table  is  best  draped  in  a  sheet,  although  this  is  not 
essential. 

Instrument  and  Dressing  Tables. — Two  of  these  are  required, 
one  on  either  side  of  the  operating  table.  As  these  tables 
often  have  pohshed  tops,  adequate  protection  must  be  pro- 
vided. This  is  best  done  by  covering  the  top  thickly  with 
newspapers,  placing  on  these  a  large  tin  tray  and  covering  all 


398     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

with  a  sheet,  draped  so  that  it  will  touch  the  floor  on  all  sides. 
This  to  protect  the  legs  and  sides. 

Douche  Bag. — This  is  needed  in  all  perineal  operations,  and 
a  more  efficient  means  of  splashing  the  wall  paper  than  an 
improperly  hung  douche  bag  can  hardly  be  devised.  A  suitable 
hook  is  provided,  preferably  in  the  mndow  frame.  An  open 
towel  is  placed  over  this  hook  so  that  the  center  of  the  towel  is 
over  the  hook.  The  bag  is  hung  on  the  hook  and  the  towel 
allowed  to  drape  over  it.  This  has  proved  an  adequate 
protection.  The  douche  bag  and  tube  are,  of  course,  prepared 
by  boiling. 

Instruments. — It  is  best  to  boil  these  where  the  physician 
and  nurse  can  keep  an  eye  on  them.  A  large  alcohol  lamp 
and  a  copper  tray  sterilizer  or  basin  will  be  satisfactory. 
If  an  alcohol  lamp  is  placed  in  the  bath-tub,  and  the  instru- 
ments are  steriHzed  there,  it  will  guard  against  the  danger 
of  upsetting  them  and  possibly  a  conflagration.  If  the  instru- 
ments are  sterilized  over  the  kitchen  stove,  servants  must  be 
warned  not  to  touch  them. 

Dressings: — For  all  ordinary  operations  the  commercially 
sterilized  gauze  and  cotton  are  entirely  satisfactory.  For 
abdominal  operations  the  dressings  should  preferably  be 
steam  sterilized  either  in  an  autoclave  or  even  in  a  Rochester 
steam  sterilizer.  If  the  latter  is  used,  the  final  sterilization 
should  be  completed  just  before  the  operation.  It  is  not  pos- 
sible adequately  to  dry  dressings  so  sterilized,  and  it  is  better  to 
have  them  warm  and  wet  than  cold  and  clammy.  Sheets  and 
towels  can  be  adequately  prepared  by  freshly  laundering  them 
and  then  ironing  with  an  iron  hot  enough  to  come  just  short 
of  scorching  them.  The  time-honored  custom  of  baking  in  the 
oven  of  the  kitchen  range  is  useless.  Such  dressings  are  not 
sterile  unless  so  scorched  as  to  be  unfit  for  use.  For  gauze 
sponges,  I  have  always  found  the  commercially  sterilized  gauze 
safe.  If  sea  sponges  are  used,  they  must  be  soaked  over 
night  in  a  1-500  bichlorid  or  a  1-20  phenol  (carbolic  acid) 
solution.     Boiling  them  destroys  their  absorptive  quahties. 


OPERATIONS    IN    PRIVATE    HOUSES  399 

Basins. — Unless  the  physician  carries  his  own  nest  of  basins, 
he  must  depend  on  the  household  supply.  Three  at  least  are 
needed  and  they  must  be  boiled.  Rinsing  or  wiping  them  out 
with  an  antiseptic  solution  is  not  sufficient. 

Scrubbing. — The  best  arrangement  for  scrubbing  up  and 
sterilizing  the  hands  can  be  made  in  the  bath-room.  Running 
water  and  previously  boiled  nail-brushes  are  used,  and  to 
obviate  stooping  over,  the  dishes  of  soap,  alcohol,  etc.,  can  be 
arranged  on  a  bread  board  placed  over  one  end  of  the  tub  and 
resting  on  the  sides  of  the  tub. 

Rtibber  Gloves.- — Steam  sterilized  and,  hence,  dry  gloves  are 
best,  but  this  is  not  always  practicable.     Boiling  is  a  method 


Pig.   156. — Rubber  gloves,   wrapped  ^<  in  a  towel  or  gauze  and 
properly    prepared    for    boiling. 

always  available  and  satisfactory.  The  gloves  must  be  boiled 
wrapped  in  gauze  or  a  towel,  and  should  always  be  boiled 
flat  so  that  the  water  can  enter  them.  The  custom  of  boiling 
gloves  rolled  up  in  a  ball  is  a  pernicious  one,  as  the  inside 
of  these  gloves  is  never  sterile  and  most  of  the  outside  is  open 
to  grave  suspicion. 

Sterile  Water. — The  night  before  operation  a  clothes-boiler 
is  filled  with  water.  In  it  are  placed  three  pitchers  and  a 
dipper  with  a  hooked  handle.  These  are  boiled  for  half  an 
hour.     The  pitchers  are  hooked  out  of  the  water  with  the  handle 


400 


GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 


of  the  dipper  and  filled,  and  then  towels  are  tied  over  their 
tops  and  they  are  set  aside  to  cool  over  night  The  next 
morning  the  clothes-boiler  full  of  water  and  the  dipper  are 
boiled  again.  Thus  by  mixing  the  cold  water  that  has  stood 
over  night  with  the  hot  water  boiled  just  before  the  operation 
a  supply  ample  for  most  operations  is  secured. 

In  emergencies,  the  bottled  distilled  water  sold  at  all  drug- 
stores is  adequate  for  the  cold  sterile  water,  except  in 
abdominal   operations.     The  water  in   the  pitchers   can    be 


Fig.  157. — Rubber  gloves  improperly  prepared  for  boiling.  They  are 
not  sterile  as  the  boiling  water  cannot  come  in  contact  with  every  part  of 
them. 

cooled  in  a  reasonably  short  time  by  pouring  cold  water  over 
the  outside  of  the  pitchers. 

Supplies  Required. — The  supplies  needed  for  an  ordinary 
operation  are  as  follows:  six  sheets;  twelve  towels;  8  ounces 
of  95  per  cent,  alcohol;  8  ounces  tincture  of  green  soap;  i 
pound  of  absorbent  cotton  (two  half-pound  rolls);  one  5- 
yard  roll  of  sterile  gauze;  one  i-yard  jar  of  iodoform  gauze;  one 
bottle  of  mercuric  chlorid  tablets;  one  2-ounce  bottle  of 
glycerin  (as  a  lubricant  for  putting  on  wet  gloves);  two  3^^ 
pound  cans  of  ether,  unopened;  three  small  coarse  (not  silk) 


PREPARATION    OP    SURGEON   AND    ASSISTANTS  401 

sponges,  size  of  lemon;  one  i-yard  package  of  sterile  gauze 
(for  the  etherizer,  to  avoid  opening  the  larger  package). 

This  list  is  best  printed  on  cards,  and  one  sent  to  the 
patient's  house  to  guard  against  details  being  forgotten. 

Nurse's  Kit. — It  is  useful  to  provide  the  nurse  who  attends 
to  the  preparing  of  houses  with  a  bag  equipped  with  what  has 
been  found  needful.  This  bag  is  small  and  easily  carried, 
but  contains  nine  basins,  twelve  brushes,  twelve  pairs  rubber 
gloves;  all  the  catgut  used  in  the  operation  (from  eight  to  ten 
boxes  being  carried);  a  rubber  sheet;  douche  bag;  razor  for 
shaving  patients  (especially  in  perineal  operations) ;  gown  and 
uniform;  the  glass  pins  (three  dozen)  used  for  protective  sheets, 
and  a  roll  of  safety  pins. 

It  is  perhaps  unnecessary  to  point  out  that  all  visible  dis- 
turbances caused  by  these  preparations  should  be  cleared 
away,  and  all  soiled  linen  and  sponges  and  water  disposed  of 
as  soon  as  possible.  This  is  particularly  desirable  when  every- 
thing has  been  prepared  in  the  patient's  room.  No  sign 
should  be  left  for  the  patient  to  see  on  recovery  from  the 
anesthetic. 

IV.  Choice  of  Time  of  Operation. — For  operations  of  election 
one  week  after  the  menstrual  period  is  best.  The  unexpected 
appearance  of  a  period  does  not  as  a  rule  contra-indicate  opera- 
tion, though  rarely  patients  show  evidence  of  shock  thirty- 
six  to  forty-eight  hours  after  operation  if  it  has  been  done 
during  a  period.  It  is  best  to  avoid  operation  at  such  a  time, 
if  possible. 

V.  Preparation  of  the  Surgeon,  Assistants  and  Nurses. — 
Persons  engaged  in  surgical  work  should  not  come  in  contact 
with  infectious  diseases.  In  all  cases  sterile  operating  suits, 
caps,  gowns  and  gloves  should  be  worn.  In  abdominal 
cases,  face  masks  as  well  are  essential.  No  one  concerned 
with  the  operation  should  come  in  contact  with  suppurating 
wounds  at  any  time  unless  protected  by  rubber  gloves.  No 
one  with  an  infected  wound  or  furuncle  on  hand  or  arm,  or 
with  acute  throat  infection  should  take  part  in  an  operation. 


402     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

The  technic  of  hand  disinfection  is  described  in  paragraph 
VIII.  For  abdominal  section,  to  secure  the  greatest  efi&ciency, 
an  assistant,  a  sterile  nurse  and  two  general  nurses  are  required. 
For  a  plastic  operation,  one  assistant,  one  sterile  nurse  and 
one  general  nurse.  In  addition,  it  adds  much  to  the  speed 
of  an  operation  if  an  extra  nurse  can  be  provided  for  the  sole 
purpose  of  threading  needles. 

VI.  Preparation  of  dressings,  towels,  sheets,  etc.,  has  been 
described  on  page  398.  Wherever  possible,  autoclave  steril- 
ized material  should  be  used. 

Sponges,  in  surgery,  are  squares  of  gauze.  Two  kinds  are 
required:  (i)  Large  squares,  six  layers  thick,  10  X  12  inches 
in  size,  with  a  piece  of  tape  six  inches  long  securely  sewed 
in  one  corner;  these  are  used  in  the  abdomen  to  pack  back 
the  intestines,  and  a  forceps  is  fastened  to  the  tape.  (2)  Small 
squares  three  or  four  inches  square,  for  mops.  All  sponges 
should  have  their  edges  sewed  to  prevent  raveling.  They 
are  put  in  packages  of  a  known  number,  are  counted 
before  the  operation  is  begun,  and  in  abdominal  operations, 
must  all  be  accounted  for  before  the  peritoneum  is  closed. 

Gowns  should  be  long  sleeved,  reaching  to  the  wrist,  so  that 
the  cuff  of  the  glove  is  turned  up  over  the  sleeve  and  all  skin 
covered. 

VII.  Suture  material  and  ligatures  are  either  permanent  or 
absorbable. 

Permanent. — i.  Silk,  either  braided  or  twisted,  the  former 
much  the  stronger,  is  sterilized  either  in  the  autoclave,  or 
by  boiling.  It  should  not  be  used  in  the  pelvis  in  infected 
cases,  as  it  tends  to  cause  a  sinus  which  persists  until  the 
knot  is  discharged. 

2.  Silver  wire  is  not  much  used  at  present.  .  It  is  sterilized 
by  boiling  with  the  instruments,  tends  to  cut  rather  badly 
and  is  painful  to  remove. 

3.  Pagenstecher  thread,  or  linen  thread  covered  with  celloidin, 
is  better  than  silk.  It  is  three  times  as  strong,  weight  for 
weight,  is  non -capillary  and  can  therefore  be  used -in  finer  sizes. 


SUTURE    MATERIAL   AND    LIGATURES  403 

It  is  chiefly  used  for  intestinal,  uterine  suspension  and  skin 
stitches,  and  can  with  benefit  be  substituted  for  silk  wherever 
the  latter  could  be  used.  It  is  sterilized  like  silk,  and  with- 
stands repeated  sterilization  better.     Barbour's  linen  thread. 


Fig.  158. — I.  A  "granny"  knot;  very  liable  to  slip,  especially  in  catgut. 
A  knot  to  be  avoided,  always.  2.  A  square  or  reef  knot;  secure  against 
slipping  in  silk  or  Pagenstecher  thread;  but  not  in  catgut  unless  a  third  tie 
is  added.  3.  The  double  surgeon's  knot.  A  very  safe  knot,  very  unlikely 
to  slip,  but  too  bulky  to  be  used  in  the  wound.  4.  Three  square  knots; 
the  ideal  knot  in  wounds;  gives  a  maximum  of  safety  with  a  minimum  of 
bulk.  5.  Surgeon's  and  square  knots;  to  be  preferred  in  tying  the  broad 
ligaments,  because  the  surgeon's  knot  prevents  slipping  until  the  second 
knot  is  tied. 

as  sold  in  all  department  stores,  is  just  as  good  as  the  much 
more  expensive  Pagenstecher,  and  is  available  everywhere. 
It  is  sterilized  in  the  same  way  as  Pagenstecher  thread  or 
silk. 


404 


GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 


4.  Horsehair,  sterilized  in  the  autoclave,  is  used  for  skin 
sutures  only,  has  no  advantage  over  Pagenstecher  thread  and 
is  in  many  respects  inferior. 

5.  Silkworm-gut  is  the  best  of  the  permanent  suture  materials, 
but  it  is  never  used  for  ligatures.  It  is  the  gut  of  the  silkworm, 
and  is  best  in  strands  ten  to  twelve  inches  long.  Longer 
than  this  it  is  too  thin  for  tension  sutures.  It  is  sterilized  in 
the  autoclave  or  by  boiling  in  plain  water,  never  in  soda 

solution.  It  does  not  withstand 
repeated  sterilization,  but  becomes 
brittle. 

Neither  silk,  hnen  thread  nor 
silkworm-gut  should  be  boiled  in 
soda  solution,  as  they  are  all  made 
brittle. 

Absorbable. — i.  Catgut,  prepared 
from  the  submucous  layer  of  the 
intestine  of  the  sheep.  It  is  used  in 
three  forms  chiefly:  (i)  Plain,  not 
hardened  to  resist  absorption;  (2) 
iodized,  hardened  with  iodin;  (3) 
chromicized,  hardened  with  bi- 
chromate of  potassium   solution. 

It  is  difficult  to  sterilize,  hence  it  is  best  to  use  the  commercial 
product,  rather  than  attempt  home  manufacture.  Commer- 
cially it  is  put  up  in  tubes  that  can  be  resterilized  by  boiling, 
and  which  are  much  the  best. 

The  non-boilable  tubes  contain  catgut  which  has  not  been 
dehydrated,  is  flexible  and  much  inferior  to  the  boilable  kind. 
The  latter  is  harsh  and  stiff,  but  can  be  made  pliable  if  the 
strand  is  dropped  in  hot  water  for  ten  seconds  only  af '•^r  the 
tube  is  broken.  Longer  immersion  than  this  renders  the  gut 
elastic  and  slippery. 

Catgut  sizes  are  00,  o,  i,  2,  3,  and  4.  Sizes  00  and  o  are 
used  for  fine  sutures  and  small  ligatures;  size  i  and  all  ordinary 
suturing;  size  2  for  ligation  in  pelvic  operations.     Size  3  is 


Ineorreef. 


Fig.  159. — The  right  and 
wrong  waj^  to  tie  interrupted 
skin  sutures. 


SUTURE   MATERIAL   AND    LIGATURES 


405 


useful  in  perineal  and  cervical  repair.     Size  4  is  too  heavy  for 
any  ordinary  use. 


Fig.  160. — Proper  way  to  tie  a  knot  when  tying  deep  in  the  pelvis. 
The  forefingers  are  close  down  on  the  knot,  and  the  strand  is  never 
jerked. 


Pig.  161. — Proper  way  to  tie  a  knot  when  tying  near  the  surface, 
The  thumbs  are  close  to  the  knot,  which  is  tied  down  by  steady  pressure 
and  never  jerked. 

In  using  catgut,  use  small  sizes  in  preference  to  large,  tie 
knots  with  the  thumbs  close  to  the  knot,  with  a  steady  pull 


4o6 


GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 


and  never  a  jerk.  Tie  the  second  knot  just  tight  enough  to 
hold  the  first  and  always  a  third  knot  on  top  of  that.  Never 
tie  with  the  stitch  crossed,  so  that  it  can  break.  Improper 
tying  is  the  commonest  cause  of  broken  strands,  especially 
when  it  breaks  at  the  second  knot.  The  knot  is  the  hardest 
and  last  part  to  absorb,  hence  the  value  of  small  sizes. 

Durability  of  catgut  is  spoken  of  as  its  duration  by  days, 


Fig.   162. — Wrong  way  to  tie  a  knot.     The  hands  are  far  away  from  the 
knot,  and  the  strain  in  the  strand  of  Hgature  material  is  excessive. 


buried  in  the  fascia.  Hence  we  speak  of  ten-day  gut  and  so  on. 
Plain  catgut  is  quickly  absorbed,  five  to  six  days  at  the  latest. 
In  the  vagina,  rectum  and  peritoneum,  catgut  will  last  only 
one-third  of  the  time  the  same  gut  will  last  in  fascia. 

Catgut  is  an  almost  ideal  suture  and  ligature,  provided  it  is 
not  used  in  too  large  sizes,  is  not  infected,  and  is  not  used 
unsupported  by  suitable  permanent  suture  material  where  it  is 
under  heavy  strain. 

Home  Preparation  of  Catgut. — Bartlett's  method  is:  (i) 
Catgut  is  wound  in  small  coils,  which  are  suspended  by  threads 
in  a  large  beaker,  the  ends  of  the  threads  being  brought  through 
a  pasteboard  cover  of  the  beaker.  This  covering  has  an  open- 
ing, admitting  a  thermometer,  the  bulb  of  which  is  on  a  level 
with  the  topmost  coil.  The  coils  must  not  touch  the  sides  of 
the  beaker;  (2)  the  catgut  is  covered  with  albolene  and  the 


DISINFECTION    OF   ABDOMINAL   SKIN  407 

whole  gradually  raised  to  2i2°F.  over  a  cumol  bath  and  kept 
there  twelve  hours;  (3)  the  temperature  is  then  increased  to 
3oo°F.  for  one  hour,  and  the  oil  allowed  to  cool;  (4)  the  coils 
are  picked  up  with  sterile  forceps,  and  kept  in  i  per  cent, 
solution  of  iodin  in  Columbian  spirits. 

2.  Kangaroo  tendon  is  obtained  from  the  tail  of  the  kangaroo. 
It  is  prepared  in  the  same  manner  as  catgut,  it  resists 
absorption  longer  than  catgut,  has  greater  tensile  strength, 
but  except  in  abdominal  hernias,  has  no  advantage  over  catgut. 

3.  Aluminum  bronze  wire  differs  from  ordinary  wire  in  that 
it  is  ultimately  absorbed.  It  is  flexible,  ties  easily  and  is 
used  in  large  abdominal  hernias,  where  tensile  strength  and 
durability  are  required.     It  is  sterihzed  by  boiling. 

VIII.  "Hand  Disinfection.^ — There  is  no  quick  and  easy 
method  of  hand  disinfection.  All  methods  depending  upon 
antiseptics  are  unreliable  and  very  hard  on  the  skin.  The 
following  method  is  satisfactory: 

(i)  Scrub  hands  and  forearms,  using  tincture  of  green  soap 
and  hot  running  water,  for  ten  minutes  by  the  clock  with  a 
moderately  stiff  sterile  brush.  Particular  attention  is  paid  to 
the  nails,  which  must  be  smooth  and  trimmed  short;  the  spaces 
between  the  fingers,  and  to  see  that  each  hand,  gets  an  equal 
amount  of  scrubbing.  (2)  Scrub  for  one  minute,  with  a  fresh 
sterile  brush,  in  70  per  cent,  alcohol.  (3)  Rinse  hands  in  sterile 
water  and  dry  on  a  sterile  towel.  Rubber  gloves  are  always, 
worn,  for  every  operation.  They  are  sterilized  by  fractional 
method  in  the  autoclave,  or  by  boiling  (flat  and  never  rolled) 
wrapped  in  gauze  or  a  towel.  The  hands  should  be  just  as 
carefully  prepared  as  if  gloves  were  not  to  be  used. 

IX.  Disinfection  of  the  Abdominal  Skin. — There  is  no 
quick  and  easy  method.  All  rapidly  antiseptic  solutions  are 
irritating  and  undependable.  It  is  easy  enough  to  secure 
favorable  healing  in  any  method  of  preparation,  when  it  is 
remembered  that  the  skin  of  persons  with  cleanly  habits 
will  in  most  cases  heal  kindly  without  any  preparation  at  all. 
A  reliable  and  safe  method  is  that  described  in  paragraph  i. 


4o8  GENERAL    TECHNIC    OF    GYNECOLOGIC    SURGERY 

Tincture  of  iodin  particularly  is  objectionable  for  the  follow- 
ing reasons:  (i)  In  strengths  of  less  than  12  per  cent,  it  will  not 
sterilize  animal  skin;  (2)  it  is  intensely  irritating  to  the  peri- 
toneum and  is  always  carried  in  on  the  operator's  gloves,  dur- 
ing the  operation;  (3)  wherever  the  intestines  are  brought  out 
of  the  wound  and  come  in  contact  with  the  skin,  there  are 
areas  of  intense  irritation  on  the  visceral  peritoneum;  (4)  it  is  a 
prolific  cause  of  postoperative  adhesions  and  a  not  infrequent 
cause  of  intestinal  obstruction;  (5)  tincture  of  iodin  in  strengths 
sufficient  to  have  a  real  antiseptic  action  on  the  skin,  will 
cause  serious  desquamation. 

At  every  section  the  abdominal  skin  should  be  protected 
with  rubber  dam,  as  the  hands  are  with  rubber  gloves. 

X.  Antiseptic  Solution.^ — The  best  surgeon,  in  abdominal 
work,  is  one  who  leans  away  from  antisepsis,  toward  asepsis. 
Hence  the  best  solution  is  plain  sterile  water.  For  superficial 
use  the  best  antiseptics  are  i  per  cent,  formalin  solution  or 
70  per  cent,  alcohol,  or  lysol  solution  (i  per  cent.).  Bichlorid 
of  mercury  solutions  are  useless.  Antiseptics  of  any  kind 
are  best  kept  out  of  the  abdomen. 

XL  Anesthesia  for  plastic  operations  is  by  gas  and  ether, 
chloroform  or  gas  and  oxygen.  The  latter  is  very  satisfactory, 
especially  for  operations  of  short  duration,  but  requires 
considerable  skill  in  the  handling  of  the  apparatus.  The  safest 
t)f  all  inhalation  anesthetics  is  unquestionably  ether,  though 
chloroform  is  very  satisfactory  provided  it  is  pure,  freshly 
opened,  never  given  in  the  presence  of  an  open  iiame  (because 
of  chlorin  degeneration)  and  never  pushed  or  hurried.  Fat 
persons  do  not  stand  chloroform  well,  as  a  rule,  and  are  more 
liable  to  chloroform  poisoning. 

For  abdominal  sections,  gas  and  oxygen  is  not  as  a  rule  satis- 
factory, particularly  in  those  requiring  work  deep  in  the  pelvis. 
It  is  difficult  or  impossible  to  secure  the  necessary  relaxation. 
In  cases  where  general  anesthesia  is  contra-indicated;  age, 
bad  kidneys,  bad  heart,  diabetes,  etc.,  various  forms  of  local 
anesthesia  are  used. 


ANESTHESIA 


409 


In  operations  on  the  cervix  the  following  is  exceedingly  use- 
ful, whether  for  repair  or  anterior  vaginal  hysterotomy : 

The  solution  used  is  3^^  of  i  per  cent,  novocain  (1-400)  with 
fifteen  drops  of  i-iooo  adrenalin  to  each  ounce.  The  in- 
jections are  made:  (i)  Around  the  cervix,  at  the  point  of 
attachment  of  the  vaginal  mucosa,  at  12,  3,  6,  and  9  o'clock, 
considering  the  cervix  as  a  clock  face.  (2)  At  3  and  9 
o'clock  straight  into   the    cervical   muscle,   parallel    to    the 


Fig.    163. — Safe  position  of  the  armij  in  anesthesia.      {After  Crossen.) 

cervical  canal.  The  operation  can  be  begun  five  minutes 
after  injection.  Perineal  nerve  blocking  is  rarely  successful, 
and  there  is  no  satisfactory  method  of  local  anesthesia  for 
plastic  operations  on  the  vagina  and  perineum. 

In  abdominal  sections,  the  skin  and  peritoneum  are  the  two 
regions  to  be  infiltrated.  The  same  solution  is  used  (1-400 
novocain)  and  the  length  of  incision  in  the  skin  is  infiltrated 
with  a  succession  of  wheals;  this  is  considerably  simplified 
if  a  line  is  painted  with  tincture  of  iodin  to  represent  the 


4IO 


GENERAL   TECHNIC   OF    GYNECOLOGIC    SURGERY 


incision.  Once  through  the  skin,  the  layers  can  be  incised 
until  the  peritoneum  is  reached.  This  is  infiltrated,  and  then 
opened.  The  abdominal  viscera  can  be  handled  with  .im- 
punity, provided  the  mesentery  and  broad  ligaments  are  not 
pulled  upon. 

Quinin  and  urea-hydrochlorid  is  not  a  satisfactory  solution 
for  infiltration  anesthesia.  It  causes  considerable  induration 
of  the  tissues  and  interferes  with  the  healing  of  the  wound. 

Position  of  the  Arms  in  Anesthesia. — The  arms  should  be 
arranged  so  that  the  palms  of  the  hands  lie  flat  on  the  pectoral 


Fig.   164. — Dangerous    position    of    the    arm    in    anesthesia,    causing 
musculospiral  paralysis.      {After  Crossen.) 


muscles,  near  the  midline  of  the  chest.  They  are  secured  by  a 
six -inch  bandage  looped  around  one  wrist  going  behind  the 
neck  and  looped  around  the  other  wrist.  Pinning  the  sleeves 
of  the  nightgown  to  hold  the  arms  is  not  satisfactory  as  the 
pins  are  pulled  out  if  the  patient  strains.  The  hands  should 
not  be  placed  under  the  patient's  hips,  nor  should  the  arms 
hang  down  even  for  a  short  time  over  the  edge  of  the  table. 
This  often  results  in  a  troublesome  musculospiral  paralysis. 
Also  the  arms  should  never  be  stretched  up  higher  than  the 


INSTRUMENTS 


411 


patient's  shoulder  level,  thus  causing  strain  on  the  brachial 
plexus. 

Spinal  anesthesia  is  not  a  safe  method. 

Infiltration  anesthesia  is  much  better. 

XII.  Instruments  in  general  are  best  sterilized  by  boiling 
for  fifteen  minutes  in  i  per  cent,  sodium  bicarbonate  solution. 
Knives  are  sterilized  by  soaking  in  10  per  cent,  carbolic  acid  in 
alcohol,  as  boiling  destroys  the  edge.  Instruments,  like 
bougies,  which  cannot  be  boiled,  are  sterilized  by  soaking, 


Pig.   165. — Dangerous  position  of  the  arm  in  anesthesia,  causing  strain 
in  the  brachial  plexus.      {After  Crossen.) 

wrapped  in  gauze,  for  at  least  an  hour  in  cold  1-50  formalin 
solution,  or  i-ioo  bichlorid.     • 

The  following  instruments  are  those  required,  as  a  minimum, 
for  plastic  operation  and  for  abdominal  sections. 


ABDOMINAL  SECTION 

3  knives 

Plain  and  toothed  tissue  forceps 

Curved  and  straight  scissors 


412     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

i8  hemostats 

12  curved  hemostats  or  clamps 

Self •  retaining  abdominal  retractor 

Hand  retractors 

Sponge  forceps 

Somers'  clamp  (for  uterus) 

2  curved  ovariotom}-  needles  (pedicle  needles) 
Sewing  needles 

Intestinal  needles  with  silk  or  linen  thread 

Needle-holder 

Rubber- covered  clamps  for  intestinal  resection 

Cautery  (for  appendix,  intestine  or  uterine  stump) 

Catgut,  silk,  silkworm-gut,  linen  thread. 

PLASTIC  OPERATION 

Weighted  speculum  (Auvard) 

3  double  tenacula  / 
Small  uterine  dilator  (Goodell) 
Heavy  uterine  dUator  (Wathen) 
Sims'  curet 

Martin  curet 

Placental  forceps  (Emmet) 

Dressing  forceps  (Thomas) 

Uterine  sound 

Bozemann  intra-uterine  douche 

Scissors  curved  and  straight 

Tissue  forceps,  plain  and  toothed 

1 8  hemostats 

2  knives 

Gelpi  perineal  retractor 

2  lion-jawed  forceps  (Jacobs) 

2  lateral  vaginal  retractors 

Sutures  (catgut  and  silkworm-gut) 

Shot  and  shot-compressor  (if  used) 

Needles  and  needle-holder. 

XIII.  The  Abdominal  Wound. — In  pelvic  surgery,  the 
straight  central  incision  is  much  the  best.  There  is  no 
advantage  in  the  right  or  left  rectus  incision.  The  curved 
incisions  across  the  lower  abdomen  (Pfannenstiel  or  Barden- 
heuer)  have  the  single  questionable  advantage  of  invisibility 


THE   ABDOMINAL    WOUND 


413 


of  scar,  as  it  is  hidden  in  the  pubic  hair.  They  have  the  follow- 
ing disadvantages:  (i)  Danger  of  injury  to  the  bladder;  (2) 
traumatism  to  the  abdominal  muscles,  as  the  fascia  flap  is 
dissected  up;  (3)  limited  room  for  work,  unless  a  huge  incision 
is  made;  (4)  a  badly  adherent  appendix  is  almost  impossible  to 
remove  through  them;  {5)  deep-seated  hematomata,  under 
the  fascia,  cause  wound  infection 
and  drainage  weeks  after  ap- 
parent satisfactory  closure. 

The  following  points  are  to  be 
remembered. 

(i)  Make  a  small  incision,  to 
be  increased  later  if  needed; 
(2)  open  the  peritoneum  high  up, 
to  avoid  the  bladder,  and  then 
enlarge  opening  downward;  (3) 
make  sure  no  intestine  is  cut  when 
peritoneum  is  opened;  (4)  keep 
fingers  out  of  wound  as  much  as 
possible,  and  handle,  with  forceps, 
but  do  not  use  forceps  to  pick  up 
intestine  or  other  viscera;  (5)  avoid 
bruising  with  retractors;  (6)  never 
bury  catgut  heavier  than  number 
I  in  the  abdominal  wound;  disre- 
gard of  this  is  the  commonest  cause  of  wound  infection;  (7) 
be  sure  of  hemostasis,  especially  in  the  muscle  (under  it)  and 
fat  layers,  otherwise  a  hematom.a  will  form.  This  is  the 
second  cause  of  wound  infection;  (8)  handle  tissues  gently 
and  do  not  tie  sutures  tight  enough  to  strangulate.  Accurate 
approximation  is  all  that  is  needed. 

Closure  of  the  Abdomen. — (i)  Continuous  number  i  chromic 
catgut  of  the  peritoneum,  everting  the  cut  edges;  (2)  two  (at 
least,  more  if  wound  is  long)  silkworm-gut  stitches  to  but  not 
through  the  peritoneum;  (3)  two  or  three  interrupted  number  i 
chromic  catgut  stitches  in  fascia:  (4)  continuous  number  i  chro- 


FiG.  166. — I.  Central  incision. 
2.  Right  rectus  incision.  3. 
Alexander  operative  incision. 
4.  Appendix  incision. 


414 


GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 


mic  catgut  stitch  for  the  fascia;  (5)  if  no  silkworm-gut  stitches 
have  been  used,  and  they  are  unnecessary  in  very  short  wounds, 
the  fat  is  closed  with  a  continuous  number  o  plain  catgut  stitch 
just  tight  enough  for  approximation.  This  stitch  is  unneces- 
sary when  silkworm-gut  stitches  are  used;  (6)  subcuticular  stitch 
of  Imen  thread;  (7)  tie  silkworm -gut  stitches,  so  that  the 
knot  is  to  one  side.  Tying  them  over  a  gauze  roll  is  not  secure 
enough. 

Dressing  of  the  Wound. — The  wound,  when  closed,  is  washed 


Fig.   167. — The  transverse  abdominal  incision. 


with  70  per  cent,  alcohol,  and  dried.  Three  strips  of  i  inch 
gauze  bandage  are  placed  on  it,  and  sealed  down  with  collo- 
dion. This  is  in  turn  thickly  dusted  with  sterile  talcum 
powder,  and  covered  with  gauze  and  strips  of  adhesive 
plaster. 

The  outer  dressing  is  removed  in  six  hours,  leaving  only  the 
collodion  strips.  An  ice  bag  is  then  placed  on  the  strips,  to 
allay  pain.  The  cold  does  not  interfere  in  the  least  with  heal- 
ing and  is  most  grateful  to  the  patient.  The  collodion  dressing 
is  removed  in  two  weeks,  if  there  is  no  trouble  in  the  wound. 


ROUTINE    AFTER-CARE    OF   PLASTICS  415 

The  silkworm-gut  and  skin  stitches  are  removed,  and  no 
further  dressing  is  as  a  rule  required.  Iniected  wounds  are 
described  under  the  complications. 

XIV.  Routine  After-care  of  Sections.^ — (i)  Elevate  head  of 
bed  on  blocks  twelve  inches;  (2)  morphin  sulph.,  gr.  }-^, 
atropin  sulph.  gr.  ^i^o — 6th  hour  p.r.n.;  (3)  cool  water  p. r.n. 
in  ounce  quantities  as  soon  as  nausea  ceases;  (4)  catheterize 
6th  hour  p.r.n.;  (5)  continuous  enteroclysis,  for  first  twenty- 
four  hours,  of  glucose  1)2  ounces,  sodium  bicarbonate  i^^ 
ounces,  water  2  pints;  run  in  at  110°  F.^ — 40  to  60  drops  to  the 
minute.  The  enteroclysis  must  be  given  through  a  large  tube, 
with  ample  provision  for  the  escape  of  gas;  otherwise  the  fluid 
is  expelled  from  the  rectum  and  the  method  is  useless;  (6)  if 
wound  is  sealed,  take  off  outer  dressing  after  six  hours  and  put 
ice-bag  over  wound;  (7)  after  twenty-four  hours  feed  by  albu- 
min water,  broth  or  milk  and  limewater  equal  parts,  i  to  2 
ounces  every  hour;  (8)  after  twenty-four  hours  give  enema  of 
milk  of  asafetida  oz.  6,  Hoffman's  anodyne  dram  i,  water 
q.  s.  ad.  I  pint;  (g)  if  much  nausea  wash  out  stomach  by  giving 
2  glasses  of  water  with  5  grains  of  sodium  bicarbonate  to 
each  glass.  If  this  does  not  stop  it,  wash  out  with  tube;  (10) 
after  forty-eight  hours  give  calomel  gr.  3^6  every  hour  for  six 
doses,  followed  in  two  hours  by  flat  magnesium  citrate  6  ounces, 
divided  into  3  doses,  one  hour  apart;  (11)  after  bowels  move 
give  soft  diet,  fifth  day  give  light  diet,  seventh  day  give  full 
diet;  (12)  if  much  distention,  give  eserin  salicylate  gr.  3^:40 
hypodermically  fourth  hour,  and  pituitrin  3^^  mil  twice  daily 
hypodermically;  (13)  if  urine  output  low,  give  spartein  sulphate 
gr.  I,  hypodermically  sixth  hour  and  force  water;  (14)  collo- 
dion dressing  off  fourteenth  day,  and  wound  dressed  thereafter 
every  other  day  with  dry  sterile  gauze;  (15)  as  a  routine  laxative 
use  compound  cathartic  pills,  one  at  bedtime.  If  too  active 
give  only  half  a  pill.     If  griping,  use  A.  B.  S.  &  C.  pill. 

Routine  After-care  of  Plastics.^ — (i)  Morphin  sulph.  gr. 
3-^,  atropin  sulph.  gr.  3-^50 — sixth  hour  p.r.n.;  (2)  water  p.r.n. 
first  twenty-four   hours;    (3)    irrigate   perineal   stitches   with 


4i6 


GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 


sterile  water  four  times  daily,  and  also  after  each  urination 
or  bowel  movement,  and  keep   sterile   vulvar   pad   in   place 


Name.. 


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Pig.    1 68. — Average  temperature  and  pulse  chart  after  an  abdominal 

section. 


after  irrigation;    (4)   if  stitches  soiled,  clean  with  cotton  on 


STAY   IN  BED  "  417 

applicator  and  peroxid  of  hydrogen,  especially  around  the 
knots;  (5)  vaginal  douche  sterile  water  every  day  after  fifth 
day;  (6)  simple  enema  once  or  twice  in  second  twenty-four 
hours;  (7)  end  forty-eight  hours,  calomel  gr.  }^  every  hour  for 
six  doses;  (8)  soft  diet  after  first  twelve  hours,  light  diet  fifth 
day,  full  diet  seventh  day;  (9)  catheterize  eighth  hour  p.r.n.; 
(10)  take  out  vaginal  packing  in  twenty-four  hours,  and  note  its 
removal  on  the  chart;  (11)  always  note  on  chart  the  number 
of  silkworm-gut  stitches  to  be  taken  out,  and  whether  they  are 
vaginal,  perineal,  anal  or  rectal. 

The  chief  complaint  after  plastic  operations,  aside  from  the 
pain  of  the  perineal  stitches  is  backache.  This  occurs  after 
any  vaginal  operation  and  is  due  to  the  dorsal  position  on  the 
table,  which  strains  the  sacro-iliac  joints  and  coccygeal  and 
other  pelvic  ligaments.  The  greatest  relief  is  change  of 
position  in  bed.  It  is  unnecessary  to  have  plastic  operation 
cases  lie  on  the  back.  They  may  turn  to  either  side,  and  it 
is  entirely  unnecessary  to  bandage  or  tie  the  knees  together. 
It  is  desirable  to  leave  the  vaginal  and  perineal  stitches  in 
place  for  some  days  after  the  patient  is  out  of  bed,  to  avoid 
the  spreading  strain  on  the  perineum  when  the  patient  sits 
down. 

XVI.  Stay  in  Bed. — Cases  with  dilatation  and  curetment 
and  repair  of  the  cervix  alone  stay  in  bed  for  five  days  and  leave 
the  hospital  on  the  seventh  day.  Ordinary  plastics  sit  up  on 
the  fourteenth  day  and  leave  on  the  seventeenth.  Cases  of 
total  prolapse  stay  in  bed  twenty-one  days  and  leave  in  twenty- 
five.  Ordinary  sections  stay  in  bed  fourteen  days  and  leave 
on  the  seventeenth.  Cases  of  Alexander  operation,  abdominal 
or  other  hernia,  Webster  operation  for  diastasis  of  the  recti 
and  abdominal  operation  for  retroversion  of  the  uterus  stay 
in  bed  twenty-one  days  and  leave  on  the  twenty-fifth.  All 
these  dates  depend  upon  a  smooth  and  uncomplicated  con- 
valescence. 

Severe  neuroses  of  long  duration  are  liable  to  follow  the 
too  early  getting  up  and  getting  about  after  abdominal  opera- 


4l8     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

tion,  and  the  tendency  unduly  to  shorten  a  patient's  stay  in 
bed — ^often  strenuously  urged  by  the  patient  herself — is  to  be 
avoided.  Early  getting  up  is  said  to  prevent  phlebitis,  but 
this  is  most  doubtful. 

XVII.  Foreign  bodies  left  in  the  abdomen  are  most  often  a 
sponge  or  hemostat.  Constant  watchfulness  is  needed  to 
prevent  this  accident.  Sponges  are  counted  and  accounted  for 
before  the  peritoneum  is  closed.  All  instruments  are  counted 
and  checked  up  in  the  same  way.  The  symptoms  are  severe 
and  sometimes  fatal  infection,  usually  with  a  most  persistent 
sinus,  and  a  palpable  mass.  A  metal  instrument  will  show  on 
an  a;-ray  plate;  the  sponge  will  not.  Either  must  be  removed  at 
the  earliest  date  possible.  Rarely  a  foreign  body  ulcerates 
into  the  rectum  and  is  discharged  spontaneously. 

XVIII.  Reasons  for  leaving  salt  solution  in  the  abdomen, 
the  solution  being  heated  to  iio°F.  and  poured  in  just  before 
the  peritoneum  is  closed  are:  (i)  Relieve  thirst;  (2)  prevent 
shock;  (3)  supply  the  fluid  that  the  patient  needs  but  often 
cannot  take  because  of  postoperative  nausea;  (4)  prevent 
reforming  of  adhesions,  by  giving  the  peritoneum  a  chance  to 
glaze  over. 

The  plan  is  a  good  one  and  should  be  routine. 

XIX.  Position  in  Bed  after  Operation.^ — An  abdominal 
section  case  is  best  kept  flat  on  her  back  for  at  least  forty-eight 
hours,  with  the  head  of  the  bed  elevated  twelve  inches.  At  the 
end  of  this  time  she  can  be  turned  to  either  side,  avoiding  all 
sudden  movements. 

The  Fowler  position  is  most  useful  in  all  cases  of  abdominal 
infection,  as  it  gravitates  infectious  fluids  to  the  comparatively 
non-absorptive  pelvis.  The  nearer  the  diaphragm,  the  more 
rapid  is  the  absorption,  hence  the/00/  of  the  bed  is  never  raised 
in  peritonitis.  In  the  Fowler  position  the  patient  is  practically 
sitting  up  against  a  bed  rest  with  the  knees  flexed  over  a 
pillow.  The  position  is  best  secured  on  the  Gatch  folding  bed. 
The  foot  of  the  bed  is  raised  eighteen  inches  only  in  the 
treatment  of  shock  and  hemorrhage. 


TREATMENT  OF  COMPLICATIONS  AFTER  OPERATION   419 

XX.  Enteroclysis. — After  every  abdominal  section  and  also 
prolonged  plastic  operation,  continuous  enteroclysis  is  desirable. 
The  solution  is  glucose  1.5  ounces,  sodium  bicarbonate  1.5 
ounces,  sterile  water  2  pints.  It  is  run  in  at  forty  to  sixty 
drops  to  the  minute,  at  a  temperature  of  iio°r.  A  faster 
flow  than  this  makes  it  difficult  for  the  patient  to  retain.  If 
she  does  not  retain  it,  it  may  be  given  high  up,  through  a  rectal 
tube,  one  pint  twice  daily.  It  relieves  thirst,  aids  diuresis  and 
is  particularly  desirable  in  drainage  cases.  Ample  provision 
must  be  made  for  the  escape  of  gas. 

XXI.  The  indications  for  and  the  treatment  of  drainage 
wounds  is  described  in  Chapter  VIII. 

TREATMENT  OF  COMPLICATIONS  AFTER  OPERATION 

Complications  after  Abdominal  Sections 

I.  Shock  is  not  common,  after  gynecologic  operations,  except 
those  in  which  a  very  large  amount  of  blood  has  been  lost,  such 
as  extra-uterine  pregnancy,  very  large  tumors  or  operations  in 
acute  septic  conditions. 

The  symptoms  are:  (i)  Subnormal  temperature;  (2)  pulse 
rapid  and  weak  (but  occasionally  slow  and  intermittent); 
(3)  pallor;  (4)  leaky  skin  with  cold  clammy  perspiration;  (5) 
shallow  and  irregular  breathing;  (6)  pinched  expressionless 
face;  (7)  pupils  dilated  and  reacting  slowly  to  light;  (8) 
restlessness  and  air  hunger,  only  if  the  shock  is  due  to  hem- 
orrhage. 

Delayed  shock,  after  abdominal  operations,  coming  on  six  to 
thirty-six  hours  after  operation  is  almost  always  due  to  internal 
hemorrhage,  except  in  operations  for  densely  adherent  pus 
tubes  with  drainage,  where  it  is  not  uncommon  without 
hemorrhage. 

Differential  diagnosis  between  internal  hemorrhages  and  shock 
is  often  exceedingly  difficult,  as  the  symptoms  are  practically 
identical.  The  diagnosis  can  be  made  much  more  easily  on 
paper  than  in  practice. 


420  GENERAL   TECHNIC    OP    GYNECOLOGIC    SURGERY 

Shock  Internal  Hemorrhage 

.   I.  No  restlessness  i.  Restlessness  marked 

2.  No  air  hunger  2.  Air  hunger  marked 

3.  Patient  apathetic  3.  Patient  anxious 

4.  No  visual  disturbance  4.  Often  loss  of  sight 

5.  Pulse  rapid  and  small  but  not       5.  Pulse   rapid,    but   larger    and 
easily  compressible  more  easily  compressible 

6.  Hemoglobin  not  lessened  6.  Lessened,  but  not  at  first 

7.  No  signs  of  fluid  in  flanks  or         7.  May  be  demonstrable 
Douglas'  pouch 

Whatever  value  this  differential  diagnosis  possesses  is  only 
in  the  recognition  of  shock  not  due  to  hemorrhage.  In  doubt- 
ful cases  where  the  patient  shows  no  sign  of  reaction  under 
treatment,  it  is  wiser  to  re-open  the  wound  rather  than  over- 
look hemorrhage. 

Treatment.- — Most  cases  can  be  avoided  by  the  following: 
(i)  As  rapid  operation  as  is  consistent  with  good  work;  (2) 
good  hemostasis;  (3)  gentle  handling  of  tissues;  (4)  expert 
anesthesia;  (5)  careful  covering  of  patient  during  operation 
and  avoiding  chilling  or  wetting. 

Curative  treatment  can  be  summarized  as  external  heat, 
stimulation,  intravenous  injection  or  transfusion:  (i)  Elevate 
foot  of  bed  eighteen  inches;  (2)  external  heat  by  hot  water  bags 
or  electric  light  frame;  (3)  bandage  extremities,  to  drive  blood 
to  vital  centers  (autotransfusion) ;  (4)  hypodermic  injection 
of  digitalin  gr.  ^-so?  strych.  sulph.,  gr.  3^^'o  every  three 
hours,  or  digipuratum  i  ampule  instead  of  the  digitalin; 
(5)  hypodermic  injection  of  atropin  sulph.  gr.  Moo  re- 
peated every  four  hours  or  often  enough  to  control  the  leaky 
skin;  (6)  hypodermic  injection  of  morphin  sulph.  gr.  3^^ 
if  very  restless;  (7)  oxygen  inhalation,  if  respiration  labored; 
(8)  enema  of  hot  strong  coffee  i  pint,  brandy  i  ounce,  given 
high  up  and  not  repeated;  (9)  if  the  shock  is  due  to  loss 
of  blood,  intravenous  injection  of  salt  solution  2000  c.c, 
given  with  a  canula  and  not  a  needle  (which  is  liable  to 
perforate  the  vein)  after  exposure  of  the  vein.  Thirty  drops 
of  i-iooo  adrenalin  solution  are  added  as  the  fluid  is  running 


TREATMENT  OF  COMPLICATIONS  AFTER  OPERATION   42 1 

in;  (10)  intravenous  transfusion  of  blood  is  better  postponed 
until  the  patient  has  reacted,  as  when  given  in  a  hurry, 
satisfactory  tests  of  the  donor's  blood  are  often  impossible 
and  hemolysis  may  result;  (ii)  artificial  respiration,  and 
oxygen  especially  if  the  shock  appears  suddenly  during 
operation. 

II.  Internal  hemorrhage,  may  be  either  continuous  or  con- 
secutive. Continuous  is  a  hemorrhage  that  never  stopped  at 
all;  consecutive  (the  commonest)  is  one  that  comes  on  some  time 
after  the  operation  is  completed,  and  due  usually  to  a  slipped 
ligature  or  breaking  of  adhesions  following  the  withdrawal  of  a 
drain.     It  may  come  from  any  vessel,    but   is    most   often 


Pig.  169. — The  arrow  points  to  the  commonest  site  of  secondary 
hemorrhage  after  operations  on  the  tubes,  ovaries  or  broad  ligaments. 
The  edge  of  the  broad  Hgament  pulls  out  of  the  grip  of  the  ligature,  and  the 
bleeding  is  from  the  ovarian  artery. 


from  the  ovarian  artery,  due  to  the  outer  edge  of  the  broad 
ligament  slipping  out  of  the  bite  of  the  ligature. 

Symptoms  are  precisely  those  described  under  the  previous 
heading  of  "shock."  A  fairly  full,  increasingly  rapid  and 
compressible  pulse,  with  restlessness  and  air  hunger,  usually 
means  hemorrhage.  The  temperature,  due  to  peritoneal  irri- 
tation from  blood-clots  is  often  elevated  and  falls.to  subnormal 


422     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

only  when  the  case  is  desperate.  The  hemorrhage,  unless 
from  a  small  vessel,  does  not  as  a  rule  cease  spontaneously. 

Treatment.- — Reopening  of  the  abdominal  wound  and 
securing  the  vessel  is  the  only  treatment.  The  patient  is  put 
in  the  high  Trendelenburg  position,  the  intestines  rapidly 
packed  off,  and  the  source  of  the  bleeding  sought  at  the  outer 
edge  of  the  broad  ligament,  where  it  will  be  found  nine  times 
out  of  ten.  The  broad  ligament  is  retied,  the  clots  and  fluid 
blood  sponged  out  and  the  abdomen  rapidly  closed.  The  after- 
treatment  is  the  same  as  for  shock. 

Regeneration  of  Blood  After  Hemorrhage. — The  body  fluids  are 
absorbed,  to  make  up  the  loss  in  volume  of  blood^ — hence  the 
thirst  and  scanty  urine  output.  The  red  cells  regenerate  more 
slowly,  hence  at  first  the  reds  show  a  low  count;  the  next 
phase  is  the  rapid  increase  of  reds,  which  outstrips  the  increase 
in  hemoglobin,  and  gives  a  picture  similar  to  chlorosis.  The 
leukocytes  are  also  increased.  The  regeneration  of  blood  after 
acute  hemorrhage  is  very  rapid,  provided  the  hemorrhage  is  not 
repeated. 

III.  Abdominal  distention  is  seen  most  frequently  in  cases 
where  there  has  been  much  handling  of  the  intestines,  as  in 
pyosalpinx  or  extensive  adhesions;  in  cases  where  there  has 
been  a  sudden  reduction  in  intra-abdominal  pressure,  as  in 
large  cysts,  fibroids  or  in  Cesarean  section;  in  peritonitis;  in 
intestinal  paresis  without  peritonitis;  and  in  intestinal  obstruc- 
tion. It  is  much  m.ore  common  in  cases  operated  on  without 
adequate  preparation.  It  is  often  alarming  in  extent,  but  is 
not  a  serious  complication  unless  the  pulse  is  elevated,  peris- 
talsis is  absent,  and  vomiting  is  persistent. 

Treatment. — Prophylactic:  (i)  Proper  cleansing  of  the  bowel 
preparatory  to  operation;  (2)  gentle  handling  of  the  intestines 
as  possible  during  the  operation,  and  as  little  of  it  as  possible ; 
(3)  eserin  salicylate  gr.  X'io  hypodermically  every  four  hours, 
pituitrin  3>^  mil  hypodermically  twice  daily  in  all  cases  where 
it  seems  likely  to  occur  (fibroids,  pus  tubes,  large  cysts  and 
Cesarean  sections). 


TREATMENT  OF  COMPLICATIONS  AFTER  OPERATION   423 

Curative  Treatment. — (i)  Rectal  tube  left  in  situ  for  several 
hours  at  a  time;  (2)  calomel  gr.  3  dry  on  back  of  tongue,  fol- 
lowed by  Hat  magnesium  citrate  solution  2  ounces  every  hour  for 
four  doses;  (3)  high  enema  of  alum  3^^  ounce  to  sterile  water 
2  pints;  (4)  high  enema  quinin  bisulphate  3^^  ounce  to  sterile 
water  2  pints;  (5)  high  compound  enema  of  magnesium  sulphate 
}''2  ounce,  turpentine  3^-^  ounce,  glycerin  i  ounce,  water  enough 
to  make  i  pint;  (6)  eserin  salicylate  gr.  \^q  with  strychnin 
sulphate,  gr.  ^^^o  every  four  hours  hypodermically;  (7)  pituitrin 
)y'2  mil  hypodermically  twice  daily;  (8)  if  vomiting  is  persist- 
ent, wash  out  stomach  and  through  tube  give  magnesium  sul- 
phate I  ounce  in  water,  2  ounces,  or  i  ounce  of  castor  oil  (hot) . 

If  the  abdominal  distention  and  vomiting  do  not  yield  to  the 
above,  they  are  due  to  peritonitis  or  intestinal  obstruction, 
both  of  which  are  described  later. 

IV.  Acute  dilatation  of  the  stomach  is  a  dangerous  form  of 
distention.  It  is  most  frequent  in  septic  cases,  but  may  occur 
in  any  case,  nearly  always  in  the  first  three  days  after  operation. 

Symptoms.- — (i)  The  patient  complains  of  pain  in  the  epigas- 
trium; (2)  the  pulse  is  rapid  and  weak,  without  demonstrable 
cause;  (3)  there  is  a  marked  globular  tympanitic  swelling  in  the 
epigastrium. 

Treatment  is  prompt  lavage,  with  the  stomach  tube,  repeated 
as  often  as  necessary  to  control  the  distention.  In  severe 
cases  this  may  be  every  two  or  three  hours.  At  the  first  wash- 
ing, the  patient  should  be  given,  through  the  tube,  one  ounce 
of  magnesium  sulphate.  She  is  given  eserin  and  pituitrin  as 
described  under  distention  of  the  stomach. 

Prognosis. — This  is  always  a  serious  complication,  demands 
prompt  treatment,  and  if  neglected  may  be  fatal.  A  variety 
due  to  thrombosis  of  the  gastric  veins,  is  always  fatal. 

V.  Postoperative  Vomiting. — Kinds:  i.  Postanesthetic,  con- 
sisting of  mucus  and  swallowed  saliva,  sometimes  bile  tinged, 
and  usually,  unless  complicated  by  some  other  factor,  of  short 
duration. 

2.  Acidosis  characterized  by  persistent  vomiting,   usually 


424     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

beginning  twenty-four  hours  or  more  after  operation  but  often 
continuous  from  the  postanesthetic  kind;  severe  epigastric 
pain  and  acetonuria. 

3.  Peritonitis,  where  there  is  exteme  and  constant  retching, 
but  at  first  only  a  frothy  mucus  is  ejected;  later  bile  colored 
and  finally  coffee  ground. 

4.  Intestinal  obstruction,  vomiting  without  effort,  and  of 
large  amounts,  first  stomach  contents,  then  bile  and  then 
stercoraceous.  As  a  prophylactic  measure,  it  is  a  wise  plan  in 
any  case  where  there  has  been  considerable  mucus  in  the  air 
passages  during  operation,  to  wash  out  the  stomach  before  the 
patient  recovers  from  anesthesia. 

When  the  patient  vomits  after  an  abdominal  operation,  she 
is  kept  on  her  back,  with  the  head  turned  to  one  side,  to  prevent 
inhalation  of  the  vomited  material.  The  vomit  is  best  caught 
in  a  towel,  rather  than  a  basin.  After  plastic  operations,  the 
patient  can  be  turned  on  her  side,  which  makes  her  care  easier. 

Treatment  depends  upon  the  cause.  Moderate  cases  will 
yield  to  the  following: 

(i)  Absolute  quiet,  flat  on  back  wdthout  a  pillow;  (2)  small 
amounts  of  hot  water  (  half  an  ounce  at  a  time);  (3)  ice  bag  or 
spice  plaster  or  mustard  plaster  to  the  epigastrium;  (4)  ii' 
persistent,  give  patient  two  glasses  of  water,  with  five  grains  of 
sodium  bicarbonate  to  each  glass,  with  the  expectation  that 
the  water  will  be  vomited  promptly  and  hence  wash  the 
stomach  out.  If  it  is  retained,  i-t  passes  out  through  the  pylorus 
and  accompHshes  the  same  purpose;  (5)  if  still  persistent ,  for- 
mal lavage  with  a  tube,  putting  in  one  ounce  of  magnesium 
sulphate  in  strong  solution  before  the  tube  is  withdrawn. 

Morphin,  heroin  and  codein  as  sedatives  usually  prolong  and 
aggravate  the  vomiting,  as  does  cold  water  or  cracked  ice 
taken  by  mouth. 

After  the  bowels  move,  the  nausea  usually  disappears. 

Cases  of  the  acidosis  t}^e  are  promptly  relieved  by  large 
doses  of  sodium  bicarbonate,  one  dram  to  a  dose,  given  every 
two  or  three  hours. 


TREATMENT  OF  COMPLICATIONS  AFTER  OPERATION   425 

Acidosis  is  a  not  infrequent  complication  after  any  operation, 
either  plastic  or  section,  where  there  has  been  prolonged  anes- 
thesia. It  is  more  common  in  patients  past  thirty-five  years  of 
age,  but  is  not  infrequently  seen  in  the  young.  It  is  character- 
ized by  severe  vomiting,  epigastric  pain,  considerable  abdominal 
distention,  marked  stupor,  and  acetonuria.  It  is,  except  in 
very  moderate  cases,  an  alarming  condition,  often  a  very  serious 
and  sometimes  a  fatal  one.  The  treatment  consists  in  the  ad- 
ministration of  large  doses  of  sodium  bicarbonate  by  mouth, 
sixty  grains  every  two  hours  being  the  minimum.  The  alkali 
can  be  given  by  bowel,  in  the  proportion  of  one  and  one-half 
ounces  of  sodium  bicarbonate  to  each  quart  of  water,  given  by 
slow,  continuous  enteroclysis,  forty  drops  to  the  minute.  In 
very  severe  eases,  time  is  a  factor,  and  these  cases  can  take 
nothing  by  mouth,  nor  retain  anything  by  the  bowel.  Here 
the  best  results  are  gained  by  giving  one  pint  of  a  five  per- 
cent, solution  of  sodium  bicarbonate  solution  intravenously, 
and  repeating  the  dose  once  daily  as  long  as  the  patient's 
symptoms  demand  it.  This  solution  is  sterilized  as  any  other 
to  be  given  intravenously,  and  the  author  has  seen  brilliant 
results  from  its  use.  Usually  one  dose  is  sufficient  and  three 
is  the  largest  number  he  has  had  to  employ. 

Cases  of  peritonitis  vomiting,  unless  controlled  by  the 
methods  described  above,  are  usually  uncontrollable  wittiout 
operation.     Intestinal  obstruction  requires   operation. 

Rectal  feeding  is  often  required,  to  give  the  stomach  an  abso- 
lute rest.  The  best  enemas  are:  liquid  peptonoids  or  pre- 
digested  beef  2  ounces  and  salt  solution  (0.7  per  cent.)  or 
sugar  solution  2  ounces,  given  every  four  hours.  A  nutritive 
enema  should  never  exceed  6  ounces,  and  4  are  better. 
Peptonized  milk  or  peptonized  beef  tea  or  broth  may  be  sub- 
stituted, but  the  predigestion  should  be  carried  to  forty-five 
minutes.  Twice  daily  a  high  enema  of  salt  or  sugar  solution 
one  pint  should  be  given  to  relieve  the  thirst. 

The  sugar  solution  is  glucose  1.5  ounces,  sodium  bicarbonate 
1.5  ounces,  v/ater  2  pints. 


426     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

VI.  Retention  of  urine  is  common,  due  to  a  reflex  nervous 
inhibition  from  pain.  It  is  much  more  common  in  plastic 
operations  than  in  sections. 

Prophylaxis. — (i)  Place  patient  on  bed  pan  and  irrigate  vulva 
and  perineum  with  hot  sterile  water;  (2)  pituitrin  i  ampule 
(i  mil)  hypodermically  and  repeated  in  3^^  mil  doses  twice 
daily  for  two  days,  if  the  inability  to  void  persists  for  that 
long;  (3)  injection  into  the  bladder  of  i  ounce  of  25  per  cent, 
boroglycerid  solution. 

Curative  treatment  is  catheterization  under  strict  aseptic 
precautions,  every  eight  hours  until  the  patient  is  able  to 
void. 

Incontinence  of  urine  is  nearly  always  an  overflow  from  reten- 
tion. The  bladder  can  be  palpated  as  distended,  and  the  relief 
is  catheterization,  followed  by  hypodermics  of  pituitrin  ^'2 
mil  twice  daily  for  three  days. 

VII.  Fever. — The  commonest  cause  of  fever  after  abdominal 
section  are:  (i)  Reaction,  when  the  temperature  occasionally 
reacts  within  twelve  hours  after  operation  to  about  100°,  and 
returns  to  normal  line  after  about  forty-eight  hours;  (2) 
ether  pneumonia;  (3)  drainage  cases,  until  the  drain  is  removed; 
(4)  peritonitis;  (5)  pelvic  cellulitis,  usually  around  a  ligature 
in  the  broad  ligament;  (6)  hematoma  in  Douglas'  pouch, 
secondarily  infected  by  colon  bacilli;  (7)  phlebitis,  (8)  phleg- 
masia abla  dolens,  or  milk-leg;  (9)  wound  infection;  (10) 
constipation. 

As  a  rule  a  persistently  high  pulse  rate,  or  a  pulse  which  is 
weak  or  irregular  is  a  much  more  grave  sign  than  an  elevation 
of  temperature,  which  often  occurs  from  trivial  causes. 

The  rise  in  temperature  following  operation,  often  to  102° 
or  103°,  is  of  no  significance,  as  a  rule,  and  requires  no  special 
treatment. 

Ether  pneumonia  is  usually  a  misnomer,  the  ether  not  playing 
the  chief  role  in  causing  pneumonia. 

Predisposing  Causes. — (i)  Elderly  patients,  who  are  particu- 
larly  prone    to    the   hypostatic    type;    (2)    fat,    short-necked 


TREATMENT  OF  COMPLICATIONS  APTER  OPERATION   427 

patients;  (3)  choking  and  vomiting  under  the  anesthetic;  (4) 
exposure  to  cold  during  anesthesia;  (5)  inexpert  anesthesia; 
(6)  administration  of  anesthesia  to  a  patient  with  a  bronchial 
cold;  (7)  tuberculosis;  (8)  operations  for  pelvic  infection. 
Lung  complications  are  much  more  common  after  sections 
than  plastics.  Most  cases  are  pleurisy  or  bronchopneumonia; 
lobar  pneumonia  is  rarer  and  also  more  serious. 

The  symptoms  and  treatment  are  those  of  bronchopneumonia, 
irrespective  of  the  operation. 

Drainage  cases,  if  gauze  has  been  used,  often  show  fever  from 
blocking  back  of  discharge  by  the  gauze  drain.  If  this  drain 
is  loosened  slightly,  slightly  pulled  out,  a  gush  of  fluid  often 
follows  it,  but  the  temperature  is  unlikely  to  subside  completely 
until  all  the  gauze  is  removed.  The  fever  is  rarely  sufficient 
to  justify  haste  in  this  respect. 

Peritonitis  is  described  under  a  separate  head. 

Cellulitis  occurs  in  the  connective  tissue  in  the  bases  of  the 
broad  ligaments  or  in  Douglas'  pouch  or  between  the  uterus 
and  bladder.  Its  symptoms  and  treatment  are  described  in 
Chapter  X. 

Hematoma  in  Douglas'  pouch  is  formed  of  blood  that  has 
oozed  out  slowly  and  collected  here,  in  the  most  dependent 
portion  of  the  peritoneal  cavity. 

It  is  usually  secondarily  infected  by  colon  bacilli  and  is 
detected  by  bimanual  examination  as  a  hard,  globular  mass 
behind  the  cervix.  In  the  majority  of  cases  it  does  not  sup- 
purate, but  undergoes  resolution  spontaneously,  the  process 
being  hastened  by  four  hot  vaginal  douches  daily.  If  it  sup- 
purates, the  posterior  vaginal  vault  becomes  convex,  and 
boggy,  the  fever  is  persistent  and  there  is  considerable  leuko- 
cytosis. In  this  case,  it  is  opened  by  puncture  of  the  posterior 
vaginal  vault,  and  T-tube  drainage,  as  described  under  pelvic 
abscess  in  Chapter  X. 

Phlebitis  is  discussed  under  a  separate  heading  (11)  in  this 
chapter,  together  with  its  most  common  manifestation, 
milk-leg. 


428     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

Wound  infection  is  discussed  on  page  433. 

VIII.  Constipation.- — The  vast  majority  of  patients  require 
laxatives  after  operation,  and  usually  in  larger  doses  than 
they  have  been  in  the  habit  of  using.  Constipation  is  most 
common  in  patients  with  enteroptosis,  weak  and  relaxed  ab- 
dominal walls,  and  diastasis  of  the  recti.  In  these  the  greatest 
difficulty  is  met  in  securing  satisfactory  movements. 

The  laxative  most  likely  to  be  satisfactory  is  that  which  the 
patient  has  been  in  the  habit  of  using,  giving,  however,  about 
double  her  usual  dose.  Mineral  oil  is  not  as  a  rule  sufficient, 
by  itself,  though  a  valuable  aid  to  other  medication.  Long- 
continued  use  of  saline  cathartics  is  liable  to  be  followed 
by  considerable  gastro-intestinal  irritation  and  discomfort, 
and  hence  it  is  undesirable.  Enemata  must  not  be  depended 
upon  alone,  as  they  cleanse  only  the  rectum.  Glycerin  supposi- 
tories are  practically  useless. 

In  patients  with  weak  abdominal  muscles,  enteroptosis  or  a 
long  history  of  constipation  can  be  benefited  by  strychnin 
sulph.  gr.  3''20  four  times  daily  by  mouth,  or  by  eserin  and 
pituitrin  as  recommended  for  distention.  If  constipation 
after  operation  is  complicated  by  vomiting,  the  only  practicable 
way  of  giving  a  cathartic  is  through  the  stomach  tube:  either 
magnesium  sulphate,  i  ounce  in  strong  solution  or  castor 
oil  2  ounces  hot  (to  thin  it)  being  poured  in  through  the  tube 
after  lavage  of  the  stomach. 

IX.  Peritonitis  after  operation  is  either  local  or  diffuse. 
The  symptoms  begin  on  the  second  or  third  day,  with  persistent 
vomiting;  rising  temperature;  rapid  and  thready  pulse;  steady 
abdominal  pain,  first  in  the  lower  abdomen  and  then  diffuse; 
peristalsis  is  diminished,  though  there  is  usually  passage 
of  both  gas  and  feces.  Peristalsis  is  entirely  absent  only  in 
diffuse  peritonitis  and  late  in  the  attack.  Vaginal  examination 
will  reveal  infiltration  of  the  pelvic  connective  tissue,  with 
its  characteristic  board-like  hardness.  The  treatment  of 
local  and  general  peritonitis  has  been  described  in  Chapter  X. 

X.  Intestinal  obstruction  is  most  often  seen  after  operation 


TREATMENT  OF  COMPLICATIONS  AFTER  OPERATION   429 

for  acute  pelvic  infection,  especially  in  those  in  which  drainage 
has  been  used,  but  may  occur  as  a  result  of  infection,  inflam- 
matory bands  or  improper  technic  of  certain  operations,  notably 
ventrosuspension  of  the  uterus. 

Symptoms.- — (i)  Persistent  vomiting;  (2)  increasing  disten- 
tion of  the  abdomen;  (3)  severe  cramp  like  abdominal  pains; 
(4)  increasing  pulse-rate;  (5)  no  passage  of  either  gas  or  feces, 
and  no  results  from  enema;  (6)  vomiting  at  first  mucus,  then 
bile  and  then  stercoraceous. 

Commonest  Sites. — Obstruction  occurs  most  in  the  rectum, 
at  about  the  level  of  the  pelvic  brim;  next  in  the  sigmoid; 
next  in  the  ascending  colon;  next  in  the  eight  inches  of  ileum 
nearest  the  caput  coli,  and  next  in  any  part  of  the  small  intes- 
tine, as  a  U  trap.  As  these  patients  are  usually  very  ill  when 
re-operated  on  and  as  time  is  a  very  vital  factor,  it  is  worth 
while  remembering  these  situations. 

Treatment: — Prompt  re-opening  of  the  abdomen,  eventration 
of  the  intestines  and  search  for  constricting  bands.  It  must  be 
remembered  that  there  is  often  more  than  one  point  of  obstruc- 
tion, and  the  search  should  be  thorough.  Unless  operation  is 
promptly  done,  a  secondary  peritonitis  develops,  which  is 
usually  fatal. 

Prognosis. — The  case  is  always  a  serious  one,  but  a  fair 
number  will  be  saved  by  prompt  operation.  The  later  the 
operation  the  higher  the  mortality. 

XL  Phlebitis,  in  gynecologic  operations,  is  usually  of  the 
septic  nonpyogenic  type,  affecting  the  uterine  and  ovarian  veins, 
and  from  there  extending  into  the  pelvic  trunks  and  to  the  iliac 
and  femoral.  It  is  most  common  after  operations  involving  con- 
siderable handling  and  ligaturing  of  the  broad  ligaments,  such 
as  operations  for  pyosalpinx,  but  can  occur  during  the  most 
uncomplicated  convalescence  from  clean  and  simple  operations. 

Cause  is  obscure.  It  is  probably  a  mild  sepsis,  due  to  non- 
virulent  bacilli,  like  the  colon  group,  lodging  in  the  inner  coat 
of  a  vein  and  causing  a  local  lesion  with  development  of  a 
thrombus.     The  exact  mechanism  is  not  known. 


430     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

Symptoms. — (i)  Deep-seated  pelvic  pain,  without  demon- 
strable lesion  by  vaginal  examination;  (2)  moderate  fever  101° 
average;  (3)  leukocytosis  12,000-14,000. 

A  constant  moderate  temperature,  with  moderate  leukocy- 
tosis and  no  point  of  localization  of  infection  points  to  a  deep- 
seated  pelvic  thrombophlebitis. 

Treatment  is  rest  in  bed,  until  the  temperature  has  been  per- 
sistently normal  for  seven  days.  It  is  claimed  that  if  patients 
are  gotten  out  of  bed  at  the  end  of  a  week  after  operation  that 
the  danger  of  thrombophlebitis  is  greatly  lessened,  but  this  is 
very  doubtful.  Nothing  further  than  rest  can  be  done  for  a 
deep-seated  phlebitis,  but  it  is  uncommon  to  have  such  a  con- 
dition alone.  The  phlebitis  seen  most  commonly  is  phlegmasia 
alba  dolens  or  milk-leg.  The  left  leg  is  the  more  commonly 
affected — rarely  the  infection  is  bilateral.  The  name  milk-leg 
comes  from  the  milky  white  appearance  of  the  skin  or  from  the 
old  belief  that  all  localization  of  infection  in  puerperal  cases 
was  due  to  metastasis  of  the  milk — lactation  being  usually 
interrupted  by  the  fever. 

Kinds  of  Milk-leg. — (i)  Cellulitic,  due  to  infection  of  the 
connective  tissue  of  the  thigh;  (2)  thrombosis  of  the  iliac  and 
deep  femoral  veins — much  the  more  common  (98  per  cent.). 

Symptoms  of  Milk-leg: — (i)  On  the  tenth  to  thirtieth  day 
after  operation  the  patient  complains  of  severe  pain  in  the 
calf  of  one  leg,  usually  the  left,  and  also  in  the  corresponding 
groin;  (2)  the  leg  is  almost  immovable,  and  any  movement 
gives  intense  pain;  (3)  the  leg  swells  rapidly,  the  skin  is  tense 
and  milk  white,  and  usually  pits  deeply  on  pressure;  (4)  there 
is  moderate  fever,  lasting  for  a  short  time,  and  subsiding  long 
before  the  swelling  shows  any  signs  of  decrease;  (5)  there  is 
usually  tenderness  along  the  whole  course  of  the  femoral  vein, 
which  can  be  felt  as  a  tender  cord;  (6)  the  swelling  may  begin 
in  the  groin  and  extend  to  the  labium  majus  on  the  affected 
side;  (7)  the  patient  shows  the  usual  signs  of  sepsis- — depression, 
gastric  disturbance,  nausea  and  flushed  cheeks. 

In  the  cellulitic  variety,  the  infection  extends  to  the  connect- 


TREATMENT    OF    COMPLICATIONS   AFTER   OPERATION      43 1 

ive  tissue  of  the  thigh  from  the  pelvic  connective  tissue,  through 
the  obturator  foramina. 

Treatment  of  Milk-leg: — (i)  Absolute  rest  in  bed;  (2)  eleva- 
tion of  the  leg,  on  pillows  or  in  a  fracture  box,  at  an  angle  of 
forty-five  degrees.  This  does  more  to  relieve  the  pain  than 
any  single  point  in  the  treatment;  (3)  evaporating  lotions  (lead- 
water  and  laudanum;  or  saturated  solution  of  magnesium 
sulphate)  covering  the  whole  leg;  (4)  paint  course  of  vein  with 
5  per  cent,  tincture  of  iodin  or  50  per  cent,  ichthyol  in  glycerin 
— of  doubtful  value;  (5)  full  diet  and  moderate  stimulation;  (6) 
no  local  massage. 

The  symptom  urgently  demanding  relief  is  the  pain  in  the 
groin.  Ice  bag  to  the  groin,  more  rarely  a  hot  water  bottle, 
elevation  of  the  leg  and  codein  gr.  j^^  or  morphin  sulph.  gr. 
3^^  hypodermically  will  give  the  greatest  relief. 

When  the  patient  is  out  of  bed,  after  the  temperature  has 
been  normal  for  ten  days,  the  swelling  of  the  leg  will  often 
increase.  This  should  be  controlled  by  an  elastic  stocking, 
and  no  massage  should  be  given  for  three  months  at  least,  and 
then  very  cautiously. 

Dangers  of  Milk-leg. — (i)  Pulmonary  embolus;  (2)  pyemia; 
(3)  gangrene. 

Prognosis  of  milk-leg  is  guardedly  favorable.  The  patient 
must  remain  in  bed  until  the  temperature  has  been  uninter- 
ruptedly normal  for  ten  days,  as  the  greatest  danger  is  pul- 
monary embolus,  from  too  early  getting  up.  Recovery  may  be 
complete,  but  convalescence  is  often  prolonged,  and  a  tem- 
porary or  permanent  lameness  may  result,  about  which  the 
patient  should  be  warned.  Gangrene  will  demand  prompt 
amputation,  and  is  a  very  serious  complication, as  it  is  prob- 
ably progressive.  Extensive  thromboses,  even  to  the  inferior 
vena  cava,  are  not  uncommon.  In  the  cellulitic  type,  if  long 
continued,  elephantiasis  is  not  unlikely,  and  suppuration  is 
common.  The  most  favorable  termination  is  complete  resolu- 
tion, but  is  rarely  attained.  The  next  most  favorable,  and  the 
commonest,  is  organization  of  the  thrombus,  obliteration  of  the 


432     GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

vein,    and   compensatory   collateral   circulation    through    the 
epigastric  and  gluteal  veins,  with  frequent  slight  disability. 

XII.  Embolism  is  a  constant  danger  of  phlebitis,  and  also 
after  operations  for  strangulated  hernia.  It  is  to  be  feared 
after  operation  for  fibroid  or  any  pelvic  tumor  with  large 
dilated  veins  in  the  broad  ligament,  and  is  peculiarly  frequent 
after  appendectomy.  The  time  of  occurrence  is  usually  late  in 
convalescence,  two  or  three  weeks  after  operation,  frequently 
after  the  patient  is  up  and  about.  Postoperative  emboli  are 
most  frequent  in  the  lungs,  but  may  occur  in  the  brain,  spleen, 
pleura,  kidney  and  mesenteric  vessels. 

As  they  frequently  follow  phlebitis,  sepsis  plays  a  part  in 
their  cause,  and  the  risk  of  embolism  is  greatly  increased  if 
the  patient,  with  phlebitis,  is  allowed  to  move  about  before 
her  temperature  has  been  persistently  normal  for  a  week. 

Pulmonary  embolism  is  the  greatest  danger  in  phlegmasia. 
It  is  not  likely  to  occur  if  the  patient  is  kept  quiet  for  a  sufficient 
length  of  time.  The  clot  may  come  from  the  femoral,  iliac  or 
uterine  veins.  A  piece  is  broken  off  and  carried  by  the  cir- 
culation to  the  right  auricle,  right  ventricle  and  pulmonary 
artery.  Small  emboli  cause  anemic  infarcts  and  pleuro- 
pneumonia, and  are  not  likely  to  be  fatal,  though  a  succession 
of  them  may  be.  The  patient  complains,  without  previous 
warning,  of  a  severe  pain  in  the  chest  and  dyspnea.  Her  color 
is  bad,  she  is  obviously  shocked,  the  heart  is  dilated  and  the 
pulse  rapid,  irregular  and  weak.  If  the  embolus  is  a  small  one, 
active  stimulation  and  oxygen  will  cause  reaction  in  a  short 
time.  If  the  embolus  is  large  the  symptoms  are  all  much  more 
severe,  and  death  is  either  instantaneous  or  so  rapid  that  no 
time  is  given  for  any  treatment. 

Mesenteric  emboli  are  found  most  frequently  in  the  mesenteric ' 
veins  of  the  transverse  colon  or  in  the  gastric  veins.  The 
symptoms  are  those  of  intestinal  obstruction  or  acute  gastric 
dilatation.  If  the  diagnosis  can  be  made  before  the  gut  is 
gangrenous,  operation,  with  resection  if  not  too  extensive,  offers 
a  chance  of  cure,  but  the  condition  is  nearly  always  fatal. 


TREATMENT    OF    COMPLICATIONS   AFTER    OPERATION      433 

XIII.  Infected  abdominal  wounds  are  rare,  with  good  tech- 
nic,  but  will  happen  at  times  in  spite  of  every  precaution. 

Causes. — (i)  Contamination  at  the  time  of  operation.  This 
can  be  due  to  poor  preparation  of  the  skin,  imperfect  cleansing 
of  the  hands  of  the  surgeon  or  his  assistants,  imperfect  sterili- 
zation of  instruments,  sponges  or  suture  material,  infected 
material  from  pelvis  or  appendix,  or  from  hair  follicle  infection, 
especially  in  groin  wounds.  (2)  Bruising  of  tissue  from  rough 
handling,  especially  from  retractors.  (3)  Poor  hemostasis  with 
consequent  hematoma,  one  of  the  commonest  causes  of  wound 
infection.  (4)  Ligatures  tied  too  tight,  so  that  the  tissue  is 
strangulated,  (5)  Too  heavy  catgut.  Nothing  heavier  than 
number  i  chromic  catgut  should  ever  be  buried  in  abdominal 
wounds,  with  the  possible  exception  of  incisional  hernia  cases, 
where  the  tension  is  extreme.  (6)  Fat  necrosis.  (7)  Post- 
operative infection,  due  to  dressings  or  improper  handling. 

It  is  common  to  speak  of  "catgut  infection,"  but  the  gut  is 
rarely  to  blame,  unless  it  is  home  prepared.  Tubes,  put  out 
by  reliable  manufacturers,  which  can  be  boiled  with  the  instru- 
ments, are  safe  and  sterile;  those  tubes  which  cannot  be  boiled 
but  are  "sterilized"  by  soaking  in  antiseptic  solution  are 
never  safe,  as  the  soaking  will  not  sterilize  them. 

Type  of  discharge  is  serum,  oil  (from  fat  necrosis),  blood  or 
pus.  Only  the  latter  means  an  infected  wound,  as  the  first 
three  cause  no  systemic  disturbance. 

Symptoms. — (i)  Elevation  of  temperature;  (2)  leukocytosis; 
(3)  throbbing  pain  in  the  wound;  (4)  brawny  induration  around 
the  wound;  (5)  bulging  under  the  skin;  (6)  as  a  late  symptom, 
reddening  of  the  skin. 

In  any  case  of  fever,  beginning  three  days  or  more  after 
operation,  the  wound  should  always  be  suspected  and  in- 
spected. 

Treatment. — The  prophylactic  treatment  is  expressed  by  the 
opposites  of  the  conditions  mentioned  as  causes.  Care  in  these 
respects  will  eliminate  all  but  a  very  small  percentage  of  in- 
fected wounds. 


434 


GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 


in 


\ 


Curative  consists  in  early  opening,  which  should  not  be 
extensive.  It  is  absolutely  unnecessary  to  remove  all  stitches 
and  allow  the  wound  to  gape.  This  only  delays  healing  and 
ruins  the  appearance  of  the  healed  wound.  A  small  opening, 
just  sufficient  to  permit  drainage  and  to  allow  the  wound  to  be 
irrigated  daily  is  all  that  is  needed. 

The  best  solutions  for  irrigation  are :  hydrogen  peroxid  one 
part,  sterile  water  three  parts,  injected 
with  a  small  glass  piston  s}Tinge  and 
washed  out  WT.th  1-3000  permanganate 
solution  followed  by  sterile  water;  Dakin's 
solution  injected  but  not  washed  out  after 
the  solution  returns  clear;  dichloramin-T, 
used  in  the  same  way  as  Dakin's  solution. 
The  irrigations  are  done  daily,  the  small 
sinus  is  drained  wath  a  very  small  ^^^ck  of 
rubber  tissue,  and  the  wound  covered  with 
gauze  held  by  Montgomery  straps.  Un- 
der this  the  average  wound  will  heal 
promptly  and  cleanly,  in  a  week  to  ten 
days,  and  its  appearance  will  be  saved. 

Frequently  the  whole  skin  and  fat  layers 
will  gape;  such  a  wound  is  cleansed  as 
described,  covered  by  a  thin  strip  of 
gauze,  the  edges  pinched  together  and 
held  in  apposition  by  adhesive  straps. 
The  dressing  is  changed  daily,  the  straps 
being  removed  by  pulling  always  toward 
the  wound.  If  the  fascia  is  involved  as  well,  the  wound  must 
be  secondarily  sutured  after  it  is  clean,  otherwise  a  hernia 
is  unavoidable.  Suturing  it  is  not  necessary  if  the  fascia  is 
Intact. 

Sinuses  are  usually  due  to  foreign  material  in  the  wound, 
such  as  heav}^  catgut  knots  or  particularly  the  silk  or 
linen  thread  used  in  ventrosuspension  of  the  uterus.  Per- 
sistent sinuses  of  this  t}^e  will  not  close  until  the  offending 


Fig.  170. — The  po- 
sition and  compara- 
tive size  of  the  open- 
ing for  draining  an 
infected  abdominal 
wound.  Removal  of 
the  stitches  is  un- 
necessary. 


TREATMENT    OF   COMPLICATIONS   AFTER   OPERATION      435 

material  is  removed.  It  is  not  necessary  to  open  the  wound. 
A  loop  of  silkworm-gut  is  passed  down  the  tract  to  the  bottom, 
is  twisted  around  several  times  and  withdrawn.  A  little  per- 
sistence is  usually  rewarded  by  catching  the  stitch  in  the 
loop  and  withdrawing  it. 

Tubercular  and  cancerous  fistulae  never  close,  and  should  not 
be  operated  upon. 

A  fecal  fistula  should  be  given  a  year  to  close  spontaneously; 


Fig.  171. 


Fig.  172. 


Pig.  171. — Separation  of  the  skin  and  fat,  as  a  result  of  superficial 
infection.     The   edges  can  be   approximated  neatly  by   adhesive  straps. 

Fig.  172. — A  wound  strapped  with  adhesive  strips,  after  separation  of 
the  skin.  The  line  of  the  wound  is  covered  with  a  thin  layer  of  gauze, 
which,  for  the  sake  of  clearness,  is  omitted. 


unless  it  is  tubercular  or  cancerous,  it  may  then  be  closed  by 
operation,  which  is  always  serious,  sometimes  very  extensive 
and  to  be  attempted  only  after  due  consideration  of  its  diffi- 
culties. 

Danger  of  hernia  in  infected  wounds  is  small  unless  the  fascia 
gapes.  Then  it  is  sure  unless  the  fascia  is  repaired  by  second- 
ary suture. 


436 


GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 


XIV.  Bursting  open  an  abdominal  wound  sometimes  occurs 
when  only  catgut  has  been  used  in  suturing  it. 

Causes  are:  (i)  Infection;  (2)  premature  absorption  of  the 
catgut;  (3)  severe  or  constant  muscular  effort.  The  wound 
gaps  widely  and  intestines  bulge   out  under   the  dressings. 


Fig  173. 


Fig.  174. 


Fig.  173. — A  "  stitch-fisher "  made  of  a  loop  of  silkworm-gut,  tied  on 
an  ordinary  wooden  applicator.  It  is  useful  in  extracting  a  buried  stitch 
from  the  bottom  of  an  infected  sinus,  as  after  ventrosuspension  of  the 
uterus.     It  must  be  boiled  before  use. 

Fig.  174. — A  "stitch-fisher"  in  operation.  The  loop  of  silkworm- 
gut  is  passed  down  the  fistula,  is  twisted  rapidly  and  withdrawn,  often 
bringing  the  buried  stitch  with  it. 


The  accident  is  not  as  serious  as  appearances  would  indicate, 
provided  it  is  treated  without  delay. 

Treatment  is:  (i)  Light  anesthesia,  (2)  closure  of  the  wound. 


TREATMENT  OF  COMPLICATIONS  AFTER  OPERATION   437 

without  freshening  the  edges,  with  close-set  interrupted  silk- 
worm-gut sutures;  (3)  insertion  of  a  narrow  rubber-dam  drain 
to  the  peritoneum  at  the  upper  and  lower  angles;  (4)  the  silk- 
worm-gut stitches  should  not  be  removed  for  three  weeks. 

XV.  Low  urine  output  after  operation  is  to  be  expected  for 
the  first  forty-eight  hours,  the  average  being  twelve  to  sixteen 
ounces  in  the  first,  twenty-four  ounces  in  the  second  twenty- 
four  hours.  If  it  falls  seriously  below  this  the  treatment  is: 
(i)  Continuous  enteroclysis  by  Murphy  drip,  giving  sodium 
bicarbonate  1.5  ounce,  glucose  1.5  ounce  to  each  quart  of  water; 
(2)  free  water  by  mouth  unless  the  patient  is  seriously  nau- 
seated; (3)  spartein  sulphate  gr.  i  hypodermically  every  four 
hours.  The  Murphy  drip  is  discontinued  as  soon  as  the  patient 
can  take  the  necessary  water  by  mouth. 

XVI.  Bed-sores  are  a  constant  danger  in  cases  where  there  is 
continual  vaginal,  urine  or  fecal  discharge.  They  should  be 
prevented  by  proper  care  and  cleansing. 

If  they  occur,  the  best  dressing  is  zinc  oxid  ointment  spread 
thickly  on  lint,  covered  by  a  larger  square  of  lint  thickly  cov- 
ered with  soap  plaster. 

XVII.  Incisional  hernia  occurs  in  about  25  per  cent,  of 
drainage  wounds.  In  ordinary  infected  wounds  it  is  not  to 
be  feared,  unless  the  fascia  is  attacked. 

The  diagnosis  and  treatment  is  described  in  Chapter  XI. 

Complications  After  Plastic  Operations 

These  are  not  as  common  as  after  abdominal  section,  though 
some  of  them,  as  vomiting,  intestinal  paresis,  phlebitis,  reten- 
tion of  urine,  are  seen  in  both  kinds  of  cases. 

I.  Vaginal  hemorrhage  is  due  to  (i)  Imperfect  suturing;  (2) 
imperfect  hemostasis;  (3)  premature  absorption  of  catgut. 
It  is  usually  profuse,  and  accompanied  by  the  passage  of  large 
clots.  It  may  occur  any  time  from  a  few  minutes  to  four 
weeks  after  operation. 

On  examination  the  vagina  is  found  filled  with  clots,  which 
are  best  removed  by  douching,  rather  than  sponging,  as  the 


43 8    GENERAL  TECHNIC  OF  GYNECOLOGIC  SURGERY 

latter  Is  exceedingly  painful.  When  the  vagina  is  distended 
by  a  wire  bivalve  speculum,  under  proper  light,  the  source 
of  the  hemorrhage  can  be  seen.  It  is  most  likely  from  (i) 
the  angle  of  the  cervical  wound,  in  amputation  of  the  cervix; 
(2)  the  angle  of  the  perineal  sulcus  in  perineorrhaphy;  (3) 
the  angle  of  the  cervical  wound  in  trachelorrhaphy;  (4)  the 


Fig.  175. — Uterine  or  vaginal  packing;  5H  yards  of  four  thickness 
gauze;  ij^  inches  wide;  put  up  in  the  ordinary  i  yard  iodoform  gauze  jar 
and    autoclave    sterilized. 

anterior  vaginal  wall,  in  cystocele  operation;  (5)  the  uterine 
cavity. 

Treatment. — Unless  a  large  vessel  is  obviously  spurting, 
which  must  be  caught  and  tied,  the  best  method  of  controlling 
the  bleeding  is  as  follows: 

(i)  With  the  patient  on  a  table  or  bed,  in  the  lithotomy 
posture,  pull  down  the  perineum  gently  with  a  narrow  Sims 
speculum,  or  two  fingers  of  one  hand;  (2)  over  the  speculum 
or  fingers,  as  a  guide  and  protection  to  the  perineal  stitches, 
pack  the  vagina  tight  full  of  sterile  gauze  strip;  using  consider- 
able pressure,  and  packing  against  the  vaginal  vaults ;     (3)  put 


TREATMENT  OF  COMPLICATIONS  AFTER  OPERATION   439 

a  large  vulvar  pad  of  sterile  gauze,  held  in  place  by  a  tight 
T-binder. 

The  hemorrhage  may  be  severe  enough  to  require  active 
stimulation,  as  described  in  the  treatment  of  internal 
hemorrhage. 

II.  Hematomata  often  occur,  In  the  anterior  vaginal  wall 
and  perineum,  after  plastic  operations.  They  are  globular 
swellings,  attended  by  considerable  pain  and  often  elevation  of 
temperature  and  pulse,  and,  in  the  perineum,  with  considerable 
discoloration  of  the  skin  of  the  perineum  and  buttocks. 

They  should  be  opened  early,  in  the  line  of  the  stitches,  to 
avoid  suppuration,  and  are  irrigated  daily  through  a  small 
catheter,  with  sterile  water.  They  do  not  as  a  rule  affect 
the  result  of  the  repair. 

III.  Retention  of  urine  is  common  in  all  plastic  operations, 
due  to  reflex  action  from  pain.  In  interposition  operations, 
the  catheter  may  have  to  be  used  during  the  patient's  entire 
stay  in  bed,  as  the  obstruction  is  in  these  cases  mechanical  also. 

In  all  plastic  operations,  when  a  catheter  has  to  be  used  re- 
peatedly, it  is  wise  to  give  urotropin,  ten  grains  four  times  a 
day,  for  the  first  three  or  four  days.  As  a  rule,  the  drug  can 
then  be  discontinued,  but  if  symptoms  of  cystitis  appear,  it ' 
must  be  continued.  The  treatment  of  cystitis  is  described 
in  Chapter  XIV. 

IV.  Infection  is  not  common  after  plastic  operations.  When 
it  occurs  it  is  usually  in  the  perineum,  and  due  to  some  gross 
error  in  technic,  or  to  perforation  into  the  rectum,  by  one 
or  more  sutures,  or  to  neglect  of  proper  after-care. 

Symptoms. — (i)  Severe,  throbbing  perineal  pain;  (2)  fever; 
(3)  leukocytosis;  (4)  by  palpation  the  hard  globular  indurated 
mass  can  be  felt;  (5)  in  severe  cases  there  is  profuse  purulent 
discharge,  gross  edema  of  the  labia  and  formation  of  false 
membrane.     This  latter  in  streptococcic  infection  only. 

Treatment. — (i)  Ordinary  cases  require  only  opening  of  the 
abscess,  in  the  suture  line  and  irrigation.  They  do  not  as  a 
rule  affect  the  result  of  the  repair. 


440  GENERAL    TECHNIC    OF    GYNECOLOGIC    SURGERY 

Streptococcic  infection  demands  the  immediate  removal  of 
all  sutures,  thorough  disinfection  of  the  infected  area  with 
carbolic  acid  (pure)  followed  by  alcohol,  and  frequent  vaginal 
irrigation.  This  is  a  serious  and  occasionally  fatal  accident 
and  always  ruins  the  repair. 

V.  Perforation  of  the  rectum  by  suturing  results  in  (i) 
Most  commonly  nothing  at  all;  (2)  infection  and  abscess 
localized    around    the    puncture;    (3)     rectovaginal     fistula. 

Perforation  of  the  bladder  may  result  in  a  troublesome  small 
vesicovaginal  fistula,  or  the  stitch  may  serve  as  a  nucleus 
for  a  vesical  stone;  the  so-called  "wandering  stitch." 

Wounds  of  the  bladder  or  rectum,  made  by  accident  in  the 
course  of  an  operation,  are  closed  at  once  by  chromic  catgut 
sutures.  The  prognosis  is  favorable  and  fistula  rarely  results, 
unless  the  wound  is  infected. 

VI.  Fistulas  from  stitch  wounds  or  incised  wounds  in  opera- 
tions vary  in  size  from  a  pinhead  to  an  opening  admitting  sev- 
eral fingers.  The  ver}^  small  ones  are  the  commoner,  because 
more  easily  overlooked. 

The  commonest  fistula  is  rectovaginal,  barely  admitting  a 
probe,  annoying  the  patient  by  escape  of  gas,  and  fecal  matter 
only  when  the  bowels  are  loose.  It  does  not  as  a  rule  close 
spontaneously. 

Vesicovaginal  or  rectovaginal  fistulse,  whatever  their  cause, 
are  closed  according  to  the  methods  described  under  the 
heading  of  Genital  Fistula  in  Chapter  XIII. 


INDEX 


Abdomen,  foreign  bodies  in,  after 
operation,  418 
salt  solution  in,  after  operation, 

418 
skin  of,  disinfection  of,  407 
Abdominal  distention  after  opera- 
tion, 422 
drainage  after  operation  in  pelvic 
infection,  216 
after-care,  218 
contra-indications,  216 
dangers,  216 
indications,  216 
methods,  216 
technic,  217 
through  posterior  vagi- 
nal vault,  218 
examination,  26 

diameters  measured  in,  26 
in  private  house,  40 
routine  points  in,  26 
myomectomy  in  uterine  fibroids, 

141 
panhysterectomy  in  cervical  can- 
cer, 86 
pregnancy,  primary,  156 

secondary,  156 
section,     abdominal     distention 
after,  422 
acidosis  after,  425 
bed-sores  after,  437 
closure  of  wound,  413 
complications  after,  419 

treatment,  419 
constipation  after,  428 
dilatation    of    stomach    after, 

acute,  426 
dressing  wound,  414 
embolism  after,  432 
enteroclysis  after,  419 
ether  pneumonia  after,  426 
fever     after,     426.     See     also 

Fever  after  operation. 
Fowler  position  after,  418 


Abdominal  section,  incisional  her- 
nia after,  224,  437 
incisions  for,  41 2 
infiltration  anesthesia  in,  409 
instruments  for,  411 
internal  hemorrhage  after,  420 
intestinal     obstruction     after, 

428 
low  output  of  urine  after,  437 
mesenteric   emboli   after,    432 
phlebitis  after,  429.      See  also 

Phlebitis  after  operation. 
position  in  bed  after,  418 
preparation  of  nurse  for,  393 

of  patient  for,  392 
pulmonary  embolism  after,  432 
retention  of  urine  after,  426 
routine  after-care,  415 
shock  after,  4 1 9.  See  aXso  Shock. 
supravaginal     hysterectomy     in 

uterine  fibroids,  138 
wall,  abnormalities  in,  220 

tumors  of,  226 
wounds,  bursting  open  of,  436 
infected,  433 
Abnormalities.     See  Anomalies. 
Abortion,  tubal,  157 

in  extra-uterine  pregnancy,  157 
Abscess,  ischiorectal,  368 
treatment,  369 
of  areola,  347 
of  Bartholin's  glands,  57 
cause,  57 

differential  diagnosis,  58 
pseudo-,  57 
symptoms,  57 
treatment,  58 
true,  57 
of  breast,  350 

Bier's  hyperemia  in,  351 
of  ovary,  201 
of  Skene's  glands,  58 
postmammary,  353 
submammary,  353 


441 


442 


INDEX 


Abscess,  tubo-ovarian,  167 

vulvovaginal,  57 
Absence  of  breast,  343 
of  genital  tract,  48 
of  menstruation,  322.     See  also 

Amenorrhea. 
of  ovaries,  185 
of  rectum,  360 
of  vagina,  53,  69 
Absorbable  sutures,  preparation  of, 

404 
Accessory  ovarj^,  185 
Acetonuria   in   extra-uterine   preg- 
nancy, 160 
Acidosis  after  operation,  425 

postoperative  vomiting  with,  423 
treatment,  424 
Acquired  atresia  of  cervix,  79 
Acromegaly,  387 

Adams-Alquie-Edebohls    operation 
in  retroversion  of  uterus, 
116  . 
technic,  117 
Addison's  disease,  386 
Adenorna  of  cervix,  malignant,  82 

of  rectum,  371 
Adenomyoma  of  uterus,  143 

of  vagina,  72 
Adherent  prepuce  of  clitoris,  60 
Adrenal  glands,  386 
Adrenalin,  386 

Alexander    operation    in    retrover- 
sion, 116 
combined  mth  section,  119 

technic,  120 
with    Pfannenstiel    incision, 
118 
technic,  119 
Alpha  ray  of  radium,  380 
Aluminum    bronze    wire    sutures, 

preparation  of,  407 
Amazia,  343 
Amenorrhea,  322 
electricity  in,  377 
functional,  323 
of  j^outh,  323 
symptoms,  326 
treatment,  323 
Ampulla  of  Fallopian  tubes,  22 
Amputation  of  cervix,  233 
advantages,  233 
disadvantages,  233 
indications,  233 
technic,  234 


Anemia  in  fibroid  tumors  of  uterus, 

134 
Anesthesia,  408 

examination  under,  32 
infiltration,    in    abdominal    sec- 
tion, 409 
novocain-adrenalin,  409 
position  of  arms  in,  410 
Angioneuroma  of  urethra,  67 
Annular  detachment  of  cervix,  230 
Anomalies  of  abdominal  wall,  220 
of  bladder,  50 
of  breast,  343 
of  cervix,  78,  79 
of  development,  48 
of  hymen,  48 
of  menstruation,  322 
of  nipple,  343 
of  ovaries,  185 
of  rectum,  50 
of  urethra,  50 
of  uterus,  103 
congenital,  49 
Anteflexion  of  uterus,  103 
causes,  103 
diagnosis,  103 
Dudley's  operation  in,  106 
dysmenorrhea  in,  103 
pessaries  in,  106 
symptoms,  103 
tents  in,  106 
treatment,  104 

alternate  methods,  106 

palliative,  106 

Wylie  drain  in,  106 

Anteposition  of  uterus,  107 

Anteversion  of  uterus,  107 

Antiseptic  solutions,  for  operation, 

408 
Anus,  atresia  of,  50 
fissures  of,  361 
imperforate,  360 
urethralis,  360 
vaginalis,  360 
^  vesicalis,  360 
'  vestibularis,  50,  281,  361 
Appendicitis,    acute,    extra-uterine 
pregnancy    and,    differentiation, 
169 
Applications,  local,  43 
indications  for,  44 
solutions  for,  44 
Applicator,  uterine,  37 
Apron,  Hottentot,  53 


INDEX 


443 


Arbor  vltae,  21,  79 

Areola,  abscess  of,  347 

Arms,  position  of,  in  anesthesia,  410 

Arteries  of  ovary,  182 

Arthritis  in  gonorrhea,  treatment, 

3.^5. 
Artificial  impregnation,  56 
light  for  examination,  38 
Assistants,     preparation     of,     for 

operation,  401 
Atmokausis  for  menorrhagia,  332 
Atresia  of  anus,  50 
of  cervix,  79 
of  genital  canal,  51 
diagnosis,  52 
prognosis,  52 
symptoms,  51 
treatment,  52 
of  Graafian  follicles,  185 
of  urethra,  303 
Atrophic  endometritis,  chronic,  127 
Atrophy,  genital,  obesity  associated 
with,  307 
of  cervix,  80 
of  ovary,  105 
of  uterus,  lactation,  151 


Backache  in  patient's  history,  25 
Backward  displacement  of  uterus, 

107 
Bacteria  in  pyelitis,  289 
Baldy  operation  in  retroversion  of 
uterus,  122 
technic,  123 
Bartholin's  gland,  19 
abscess  of,  57 
cause,  57 

differential  diagnosis,  58 
pseudo-,  57 
symptoms,  57 
treatment,  58 
true,  57 
chronic   infected,   instillations 

for,  45 
cysts  of,  61 

inflammation      of,      Saenger's 
macule  in,  58 
Battey's     operation     for     uterine 

fibroids,  143 
Bed,   position  in,  after  operation, 

418 
Bed-sores  after  operation,  437 
Beta  ray  of  radium,  380 


Bier's    hyperemia    in    abscess    of 

breast,  351 
Bimanual  examination,  29 

reposition     in     retroversion     of 
uterus,  no 
Birth  canal,  injuries  of,  228 
classification,  228 
repair,  228 
Bivalve  speculum,  33 

right  method  of  removal,  35 

of  using,  34 
skeleton,  36 
Bladder,   283 
anatomy,  283 
blood-supply  of,  283 
cancer  of,  300 

contraction  of,  in  cystitis,  298 
defects  of,  50 
diseases  of,  293 
exstrophy  of,  50,  22a:,  302 
irrigations,  46 

in  cystitis,  technic,  296 
overdistention  of,  302 
papilloma  of,  299 
stone  in,  301 
trigone  of,  283 
tuberculosis  of,  299 
Bleeding  at  menopause,  334 
in  cervical  polyps,  97 
in  fibroid  tumors  of  uterus,  134 
irregular,   in   cancer    of    cervix, 

irrespective    of    menstruation, 
330 
Blind  fistula  in  ano,  internal,  362 

external,  362 
Blood,    regeneration   of,    after   in- 
ternal hemorrhage,  422 
Blood-letting,  local,  46 
Blood-vessels  of  uterus,  21 
Boric  acid  tampons,  42 
Boroglycerid  tampons,  42 
Breast,  343 
abscess  of,  350 

Bier's  hyperemia  in,  351 
absence  of,  343 

anomalies  of  development,  343 
cancer  of,  356.     See  also  Cancer 

of  breasts 
cystadenoma  of,  355 
cysts  of,  355 
diseases  of,  343 
inflammatory,  348 
non-inflammatory,  347 


444 


INDEX 


Breast,  fibro-adenoma  of,  354 

hormone  of,  389 

hypertrophy  of,  347 

inflammation     of,     acute,     348. 
See  also  Mastitis. 

method  of  examination,  354 

neuralgia  of,  348 

sarcoma  of,  358 

supernumerary,  343 

sjTjhiHs  of,  354 

tuberculosis  of,  354 

tumors  of,  354 
benign,  354 
malignant,  356 
Breast-pump,  346 
Broad  ligaments  of  uterus,  102 
Bulbocavernosus  muscles,  24 
Bullet  forceps,  36 
Burns,  .r-ray,  378 
Bursting  open  of  abdominal  wound, 

436 
Byrne  cautery  method  in  cer\'ical 

cancer,  91 


Cachexia  in  cancer  of  cervis,  83 
Calculus,  renal,  292 
ureteral,  293 
vesical,  301 
Cancer  en  cuirasse,  357 
of  bladder,  300 
of  breast,  356 

after-treatment,  358 
age  in,  356 
causes,  356 
diagnosis,  357 
frequency,  356 
hard,  356 
inoperable,  357 

treatment,  358 
metastasis  in,  357 
prognosis,  358 
scirrhous,  356 
symptoms,  357 
treatment,  357 
varieties,  356 
of  cen.'ix,  So 

abdominal      panhj'sterectomv 

in,  86 
age  of  occurrence,  80 
cachexia  in,  83 
caulifloiver,  81 
causes,  80 

of  death  in,  83 


Cancer  of  cervdx,  cautery  in,  89 

classification,  81 

clinical,  81 
history,  83 

diagnosis,  83 

direction  of  metastasis,  82 

foul  discharge  in,  83 

frequency,  80 

indications  for  operation,  85 

indurating,  81 

interstitial,  81 

irregular  bleeding  in,  83 

mesothorium  in,  92 

palliative  treatment,  length  of 
life  after,  92 
methods,  89 

pathologic,  81 
tj'pes,  81 

prognosis  after  operation,  89 

radical  operations  in,  86 

radium  in,  382 

recurrence,  treatment,  92 

squamous-cell,  81 

symptoms,  83 

vaginal  hj'sterectomy  in,  86 
technic,  88 

.r-ray  in,  91 
of  Fallopian  tubes,  primary,   180 
of  ovary,  204 
of  rectum,  372 

operative  treatment,  methods, 

373 
of  uterus,  125 
diagnosis,  126 
prognosis,  126 
symptoms,  125 
syncytial,  126 
treatment,  126 
varieties,  126 
of  vagina,  inoperable,  treatment, 
70 
metastasis,  70 
primary,  79 
prognosis,  70 
secondary,  69 
sj^mptoms,  70 
treatment,  70 
of  vulva,  62 
Carcinoma.     See  Cancer. 
Cardinal  ligaments  of  uterus,   21, 

102 
Caruncles,  urethral,  67 

myrtiform,  19,  48 
Catarrh,  chronic  cervical,  93 


INDEX 


445 


Catgut  sutures,  durability,  406 
home  preparation, '406 
infection  from,  433 
preparation  of,  404 
sizes  of,  404 
Catheter,  ureteral,  uses,  288 
Catheterization,  technic,  284 
Cauliflower  cancer  of  cervix,  81 
Cautery  in  cervical  cancer,  89 

knife,  electric,  uses  of,  377 
Cellulitis,    pelvic,    208.     See    also 
Parametritis. 
fever  from,  after  operation,  427 
Cervical  canal,  hydatidiform  sar- 
coma of,  149 
Cervicitis,  93 
Cervix,  78 

abnormalities,  79 
adenoma  of,  malignant,  82 
amputation  of,  233 
annular  detachment  of,  230 
atresia  of,  79 
atrophy  of,  80 
cancer  of,  80 
chronic  catarrh  of,  93 
cicatricial  bands  of,  232 
conical,  78 

corpus  mucosum  of,  79 
cylindrical,  78 
ectropion  of,  93 

elongation  of,  hypertrophic,   95 
endothelioma  of,  malignant,   82 
erosion  of,  94 
simple,  85 
symptoms,  94 
treatment,  95 
eversion  of,  93 
examination  of,  methods,  79 
gonorrhea  of,  313 
hypertrophic  elongation,  95 
hypertrophy  of,  95 
instillations  into,  45 

colic  from,  46 
lacerations    of,     229.     See    also 

Lacerations  of  cervix. 
leukorrhea  from,  336 
treatment,  340 
gonorrheal  type,  340 
treatment,  340 
mucosa  of,  79 
myoma  of,  95 
normal  anatomy,  78 
polyps    of,     85,     96.     See    also 
Polyps,  cervical. 


Cervix,  relations  of,  78 

repair  of,  232 

sarcoma  of,  85,  98 

stenosis  of,  electricity  in,  377 

superinvolution  of,  80 

syphilis  of,  85 

tuberculosis  of,  98 

ulceration  of,  98 
Chancre  of  vulva,  60 
Change  of  life,  333 
Childbirth,    pathological   sequelae, 
256 

gonorrhea  in,  309 
Chlorosis,  324 
Chorionepithelioma,  126 

of  vagina,  69 
Cicatricial  bands  of  cervix,  232 
Cirrhosis  of  ovary,  185 

dysmenorrhea  from,  186 
Clamp  and  cautery  in  hemorrhoids, 

366 
Climacteric,  333 
Clitoris,  18 

adherent  prepuce  of,  60 

hypertrophy  of,  53 
Cloaca,  360 
Coccygodynia,  260 
Coccyx,  fracture  of,  260.     See  also 
Fractures  of  coccyx. 

pain  in,  causes,  260 

painful  mobility,  causes,  260 

rupture  of,  229 
Coffey's  operation  in  retroversion 

of  uterus,  124 
Coitus,  painful,  61 
Colic,  uterine,    from    instillations, 

.46 
Collin's  bivalve  speculum,  2>2> 
Colpitis,  74.     See  also  Vaginitis. 
Colpocleisis,    in    vesicovaginal   fis- 
tula, 281 
Condyloma,  60 

flat,  60 

pointed,  60 

of  vagina,  70 
Congenital  anomalies  of  uterus,  49 

atresia  of  cervix,  79 

malformations  of  rectum,  360 
Congestion  of  ovary,  186 
Conical  cervix,  78 

nipple,  347 
Connective  tissue,  pelvic,  anatomy, 

207 
Constipation   after  operation,   428 


446 


INDEX 


Corpus  albicans,  185 
luteum,  185 
cysts,  187 

symptoms,  189 
mucosum  of  cervix,  79 
Cortex  of  ovary,  23 
Counter-irritation  with  iodin  solu- 
tion, 44 
Cretinism,  385 
Cribriform  hymen,  48 
Crista  lactea,  343 
Curetforceps,  37,  38 
Curettage  in  fibroids  of  uterus,  136 
Cylindrical  cervix,  78 
Cystadenoma  of  breast,  355 
of  ovary,  187 
diagnosis,  190 
serous,  188 
symptoms,  190 
treatment,  193 
Cystitis,  293 

acute,  course,  295 
pathology,  294 
treatment,  295 
causes,  294 

chronic,  consequences,  297 
course,  295 
pathology,  294 
symptoms,  295 
treatment,  296 
contraction  of  bladder  in,  298 
diagnosis,  295 

irrigation  of  bladder  in,  296 
kinds,  294 
of  aged,  298 
pathology,  294 
prophylaxis,  295 
routes  of  infection,  293 
site  of  infection,  294 
treatment,  295 
ulcers  in,  297 
vetularum,  298 
Cystocele,  263 
causes,  264 
diagnosis,  265 
Goffe  operation  in,  269 
Hirst's  (B.  C.)  operation  in,  269 
JVlartin  operation  in,  268 
mechanism,  264 
operative  treatment,  268 
pessaries  in,  265 
Stoltz  purse-string  operation  in, 

268 
symptoms,  265 


Cystocele,  treatment,  265 
Watkins-Freund-  W  e  r  t  h  e  i  m 
operation  in,  269 
Cystoscopy,  285 

by  air  distention,  285 
by  water  distention,  285 
Cysts,  Nabothian,  puncture  of,  46 
of  Bartholin's  gland,  61 
of  breast,  355 
of  corpus  luteum,  187 

symptoms,  189 
of  Gartner's  duct,  71 
of  labia,  61 

of  Morgagni,  155,  180 
of  oophoron,  186 
of  ovary,  186 
accidents  to,  195 
carcinomatous    degenerations, 

198 
characteristics,  186 
classification,  186 
clinical  classification,  186 
degenerations,  198 
dermoid,  188 

symptoms,  190 
diagnosis,  190 

differential,  191 
follicular,  186,  189 
glandular,  diagnosis,  190 

symptoms,  190 
hemorrhage  in,  197 
histologic  classification,  186 
implantation     metastases     in, 

i99_ 
infection  and  suppuration  in, 

199 
intraligamentary,    without 

pedicle,  treatment,  194 
marsupialization,  195 
ovigenous,  186 

papillary  degeneration  in,  198 
pedicle,  189 

twisted,  19s 
pregnancy     and,     differentia- 
tions, 191 
prognosis,  199 
proliferating,  186 
pseudomucin,  187 
rate  of  growth,  189 
rupture  of,  196 
salpingitis  and,  differentiation, 

169 
symptoms,  189 
tapping,  194 


INDEX 


447 


Cysts  of  ovary,  thrombosis  of  pelvic 
veins  in,  196 
treatment,  192 
of  paroophoron,  186 
of  parovarium,  186,  188 
symptoms,  190 
with  pedicle,  treatment,  193 
of  vagina,  71 

Deciduoma  malignum,  126 
Defects  of  bladder,  50 
Dentated  hymen,  48 
Dermatitis  of  labia  and  perineum, 

acute,  59 
of  nipple,  malignant,  347 
Dermoid  cysts  of  labia,  61 

of  ovary,  188 
symptoms,  190 
Desiccation,  377 

Detachment  of  cervix,  annular,  230 
Diabetes    in    fibroids    of    uterus, 

134 
Diagnosis,  aids  to,  33 
Diastasis  of  recti,   with   viscerop- 
tosis, 220 
Digital  examination,  28 
Dilatation  in  fibroids  of  uterus,  136 
of  stomach,  acute,  after  opera- 
tion, 423 
Diphtheritic  vaginitis,  75 
Discus  proligerus,  184 
Disinfection,  hand,  407 

of  abdominal  skin,  407 
Displacements  of  ovary,  diagnosis, 
200 
treatment,  201 
of  uterus,  anterior,  103 
backward,  107 
Distention,  abdominal,  after  opera- 
tion, 422 
Dorsal  position,  28 
Douche   bag  for  home  operation, 
398 
intra-uterine,  47 
vaginal,  44 

directions  for,  44 
uses,  44 
Douglas'     pouch,    hematoma    in, 
fever  from,  after  operation,  427 
Dressing  forceps,  uterine,  37 

table  for  home  operation,  397 
Dressings  for  home  operation,  398 
preparation  of,  for  operation,  402 
Duct,  Gartner's,  49 


Ducts,  Mullerian,  49 
Ductless  glands,  384 
Dudley's   operation   in  anteflexion 

of  uterus,  106 
Duverney's  glands,  19 
Dwarfism,  387 
Dysmenorrhea,  325 

causes,  325 

effect  of  marriage  on,  327 

electricity  in,  377 

from  cirrhosis  of  ovary,  186 

in  anteflexion  of  uterus,  103 

membranous,  327 

nasal  treatment,  326 

operative  treatment,  327 

sterility  from,  327 

treatment,  326 
Dyspareunia,  61 
Dystopic  kidney,  259 
Dystrophia  adiposogenitalis,  387 

Ectopic  gestation,  156.     See  also 

Extra-uterine  pregnancy. 
Ectropion  of  cervix,  93 
Edebohls'    suspension    in    floating 

kidney,  258 
Electric  cautery  knife,  uses  of,  377 

treatment,  39 
Electricity,  374 

apparatus  needed  for,  374 
faradic,   for  intra-uterine   treat- 
ment, 375 
properties,  375 
for  intra-uterine  treatment,  375 
contra-indications,  376 
technic  of  application,  376 
for  uterine  hemorrhage,  376 
galvanic,  for  intra-uterine  treat- 
ment, 375 
properties,  374 
high  frequency  current,  uses  of, 

378 
in  amenorrhea,  377 
in  cervical  stenosis,  377 
in  dysmenorrhea,  377 
sinusoidal,  for  intra-uterine  treat- 
ment, 376 
properties,  375 
Elephantiasis  of  vulva,  62 
Elongation,  hypertrophic,  of  cervix, 

95 
Embolism  after  abdominal  section, 

432 
Emmenagogues,  324 


448 


INDEX 


Emmet's  curet  forceps,  37,  38 
operation  for  delayed  repair  of 

perineum,  244 
trachelorrliaphy  in  lacerations  of 
cervix,  232 
Emphysematous  vaginitis,  74 

treatment,  77 
Endocervicitis,  93,  313 
Endocrin  glands,  384 

active  materials,  384 
anomalies    due    to    disturbed 

function  of,  390 
extracts,  intramuscular  admin- 
istration, 390 
methods   of   administration, 

390 
interglandular  relations,  384 
Endometritis,  127 
acute,  causes,  127 
causes,  128 
chronic  atrophic,  127 
causes,  127 

hyperplastic  glandular,  127 
interstitial,  127 
curettage  in,  129 

examination' of  material  from, 

130 
perforation  of  uterus  from,  130 
regeneration  of  endometrium, 

after,  130 
technic,  129 
gonorrheal,  314 
symptoms,  128 
treatment,  128 
palliative,  129 
radical,  129 
tuberculous,  128 
varieties,  127 
Endometrium,  102 

during  menstruation,  319 
regeneration  of,  after  curettage  in 
endometritis,  130 
Endosalpingitis,  179 
Endothelioma  of  cervix,  malignant, 
82 
of  ovary,  205 
Enteroclysis  after  operation,  419 
Epiphysis  cerebri,  387 
Epispadias,  50 

Epithelial  cysts  of  vagina,  71 
Epithelioma  of  vulva,  62 
Epoophoron,  183 
Erect  position,  32 

for  examination,  32 


Erosion  of  cervix,  94 
simple,  85 
symptoms,  94 
treatment,  95 
Ether  pneumonia  after  operation, 

426 
Eversion  of  cervix,  93 
Examination,  26 
aids  to  diagnosis,  33 
artificial  light  for,  38,  39 
bimanual,  28 
digital,  28 

for  tubes  and  ovaries,  29 
in  private  house,  39 
lubricants  for,  29 
methods,  25 
of  abdomen,  26 

diameters  measured  in,  26 
in  private  house,  40 
routine  points  in,  26 
of  young  girls,  32 
pelvic,  positions  for,  28 
preparation  of  patient,  28 
rectal,  29 
table  for  office,  38 
under  anesthesia,  32 
Exophthalmic  goiter,  385 
Exstrophy  of  bladder,  50,  221,  302 
External  female  genitalia,  17 
Extra-uterine  pregnancy,  156,  162 
acetonuria  in,  160 
active  stimulation  in,  161 
acute  appendicitis  and,  differ- 
entiation, 169 
causes,  156 
classification,  156 
clinical  history,  159 
development,  157 
diagnosis,  159 

dift'erential,  159 
erosion  of  tubal  wall  in,  158 
metrorrhagia    after    operation 

in,  162 
pelvic  hematocele  in,  158 
removal  of  both  tubes  in,  162 
salpingitis  and,  differentiation, 

169 
symptoms,  159 
terminations,  157 
treatment,  160 
tubal  abortion  in,  157 


Fallopian  tubes 
ampulla  of,  22 


22,  153 


INDEX 


449 


Fallopian  tubes,  arteries  of,  155 
caliber,  23,  155 
cancer  of,  primary,  180 
congestion  of,  155 
diseases  of,  153 
divisions,  155 
examination  for,  29 
fimbriae  of,  22,  155 
inflammation     of,     164.     See 

also  Salpingitis. 
infundibulum,  155 
interstitial  portion,  155 
isthmus,  22,  155 
leukorrhea  from,  337 

treatment,  341 
lymphatics  of,  155 
muscular  coat,  23 
nerves  of,  155 
normal  anatomy,  153 
proper,  155 
structure,  153 
tuberculosis  of,  179 
cause,  179 

contra-indications  to  opera- 
tion in,  180 
pathology,  179 
progress,  180 
symptoms,  179 
treatment,  180 
tumors  of,  180 
benign,  180 
malignant,  180 
uterine  mouth,  155 
uterine  portion,  22 
veins  of,  155 
Faradic  electricity  for  intra-uterine 
treatment,  375 
properties,  375 
Female  genitalia,  external,  17 
Femoral  hernia,  225 
Fever  after  operation,  426 
from  cellulitis,  427 
from   hematoma   in    Douglas' 

pouch,  427 
in  drainage  cases,  427 
predisposing  causes,  426 
Fibro-adenoma  of  breast,  354 
Fibro-adenomatous     cervical 

polyps,  96 
Fibroid  cervical  polyps,  96 
tumors  of  uterus,  131 

abdominal  myomectomy  in, 

141 
anemia  in,  134 

29 


Fibroid  tumors  of  uterus,  Battey's 

operation  for,   143 
bleeding  in,  134 
calcification  in,  132 
cause,  131 
degenerations,  132 
diabetes  in,  134 
dilatation  and  curettage  in, 

136 
edematous  degeneration  in, 

132 
effect  on  pregnancy,  135 
frequency,  131 
heart  lesion  in,  134 
hyaline  degeneration,  132 
hyperthyroidism  in,  134 
hysterectomy  in,  supravagi- 
nal abdominal,  138 

vaginal,  137 
in  pregnancy,  143 
interstitial,  131 
intraligamentary,  131 
intramural,  131 
irritable  nervous  system  in, 

134 
leukorrhea  in,  135 
life  history,  132 
ligation  of  arteries  in,  143 
malignant   degeneration   in, 

132 
morcellation  in,  142 
myxomatous     degeneration, 

132 
pain  in,  134 

presence  of  tumor  in,  134 
radium  in,  136 
recurrent,  143 
red  degeneration  in,  132 
secondary  symptoms,  134 
site  of  development,  131 
styptics  in,  135 
submucous,  131 
subserous,  131 
symptoms,  134 
thrombosis  in,  132 
treatment,  135 

palliative,  135 

radical,  137 
vaginal  discharge  in,  135 
vaginal  myomectomy  in,  142 
a;-ray  in,  136 
Fibro myoma  of  uterus,   131.     See 
also  Fibroid  tumors. 
of  vagina,  72 


450 


Index 


Fimbriated  extremity  of   Fallopian 

tubes,  2  2 
Finsen  light,  383 
Fissure,  vesical,  inferior,  50 
superior,  50 
vesico-urethral,  301 
Fissured  nipple,  344 
symptoms,  344 
treatment,  344 
Fissures  of  anus,  361 
Fistula  after  plastic  operation,  440 
Fistulae,  genital,  278 
varieties,  278 
in  ano,  361 

blind  external,  362 

internal,  362 
complete,  362 
diagnosis,  362 
symptoms,  362 
treatment,  362 
rectovaginal,  diagnosis,  281 

treatment,  281 
uretero vaginal,  diagnosis,  281 

treatment,  282 
vesicocervicovaginal,  282 
vesicovaginal,  279 
diagnosis,  278 
Fixation,  vaginal,  in  retroversion  of 

uterus,  125 
Flat  condyloma,  60 
Flexion  of  uterus,  lateral,  107 
Floating  kidney,  256,  292 
cause,  256 
diagnosis,  257 

Edebohls'  suspension  in,  258 
symptoms,  256 
treatment,  258 
Floor,  pelvic,  24 

lymphatics  of,  24 
Follicles,  Graafian,  23,  103 
atresia  of,  185 
stages  of  maturity  of,  184 
Nabothian,  96 
Follicular  cysts  of  ovary,  186 

symptoms,  189 
Forceps,  bullet,  36 
curet,  37,  38 _ 
uterine  dressing,  37 
Foreign  bodies   in   abdomen   after 
operation,  418 
in  rectum,  363 
in  vagina,  71 
Fossa,  ovarian,  182 
navicularis,  19 


Fowler  position  after  operation,  418 
Fracture  of  coccyx,  260 

diagnosis,  261 

mechanism,  260 

terminations,  260 

treatment,  261 
Fritsch-Bozemann    intra-u  t  e  r  i  n  e 

douche,  47 
Fulguration,  377 
Functional  amenorrhea,  323 
Fundus  of  uterus,  cancer  of,  125. 

See  also  Cancer  of  uterus. 
Fungi  in  vaginitis,  75 

Galactocele,  355 
Galvanic     electricity     for     intra- 
uterine treatment,  375 
properties,  374 
Gamma  ray  of  radium,  380 
Gartner's  duct,  49,  183 

cysts  of,  71 
Generative  organs,  external,  17 

internal,  20 
Genital  atrophy,  obesity  associated 
with,  387 
canal,  atresia  of,  51 
diagnosis,  52 
prognosis,  52 
symptoms,  51 
treatment,  52 
fistulse,  278 

varieties,  278 
organs,  hypertrophy  of,  53 
tract,  absence  of,  48 
anomalies,  48 
development,  48 
Genupectoral  position,  30 
Gestation,  ectopic,   156.     See  also 

Extra-uterine  pregnancy. 
Gigantism,  387 

Gilliam  operation   in   retroversion 
of  uterus,  123 
Mayo's  modification,  123 
Girls,  examination  of,  32 

menorrhagia  in,  329 
Glands,  Bartholin's,  19 
of  Duverney,  19 
endocrin,  384 
Skene's,  19 
vulvovaginal,  19 
Glandular    cysts    of    ovary,  diag- 
nosis, 190 
symptoms,  190 
hyperfunction,  384 


INDEX 


451 


Glandular  hypofunction,  384 
Glass  jars,  39 
Gloves,  rubber,  39 
Glycerin-ichthyol  tampons,  42 
Goffe  operation  in  cystocele,  269 
Goiter,  exophthalmic,  385 
Gonococcus,  growth,  306 
habitat,  306 
latency,  306 

preparation  of  smear,  307 
staining,  308 

in  doubtful  cases,  308 
Tiedemann's  modification,  308 
variations  under  culture,  306 
Gonorrhea,  305 
arthritis  in,  treatment,  315 
cervical,  313 
complications,  315 
diagnosis,  307 
in  children,  309 

acute,  treatment,  310 
chronic,  complications,  311 
prognosis,  311 
treatment,  310 
method  of  infection,  309 
recurrences,  311 
symptoms,  310 
treatment,  310 
kinds,  309 
latency,  307 
lurking  places,  307 
mode  of  infection  with,  305 
ophthalmia  in,  treatment,  315 
order  of  infection  in,  307 
peritonitis  in,  treatment,  315 
prognosis,  309 
serum  treatment,  315 
vaccines  in,  315 
vaginitis  from,  75 
treatment,  76 
Gonorrheal  endometritis,  314 
pyosalpinx,  streptococcic  pyosal- 

pinx  and,  differentiation,  171 
type  of  cervical  leukorrhea,  340 
urethritis,  311 

complications,  312 
prognosis,  311 
symptoms,  311 
treatment,  312 
Goodman-von  Ott  curve  in  men- 
struation, 321 
Graafian  follicles,  23,  183 
atresia  of,  185 
gtages  of  maturity  of,  184 


Granular  vaginitis,  diffuse,  74 
Gubernaculum  of  Hunter,  183 
Gynatresia,  51 

diagnosis,  52 

prognosis,  52 

symptoms,  51 

treatment,  52 

Hand  disinfection,  407 
Heart,  myoma,  134 
Hematocele  pelvic,  158,  213 

in  extra-uterine  pregnancy,  158 
Hematocolpometra,  51 
Hematocolpos,  51 
Hematoma  after  plastic  operation, 

439 
in   Douglas'   pouch,  fever   from, 

after  operation,  427 
of  ovary,  tarry,  187 
parametrial,  213 
Hematometra,  51 
Hematosalpinx,  51,  162 
Hemelythrometra,  51 
Hemorrhage     from     uterus,     elec- 
tricity in,  376 
in  ovarian  cysts,  197 
internal,  after  operation,  421 
shock    after     operation     and, 
differentiation,  419 
vaginal,  after  plastic  operation, 

437 
treatment,  438 
Hemorrhoids,  363 
causes,  364 

clamp  and  cautery  in,  366 
external,  363 

symptoms,  365 

treatment,  365 
histology,  364 
internal,  364 

diagnosis,  365 

symptoms,  365 

treatment,  365 
ligature  in,  367 
operation    in,    after    treatment, 

367 
treatment,  operative,  366 
varieties,  363 
Hermaphroditism,  true,  54 
Hernia,  221 
femoral,  225 

incisional,  after  abdominal  opera- 
tion, 224,  437 
inguinal,  224 


452 


INDEX 


Hernia,  pudendal,  67 
umbilical,    222.     See    also    Um- 
bilical  hernia. 
High   frequency  current,   uses  of, 

378 
Hilus  of  ovary,  23,  182 
Hirst's  (B.  C.)  double  tenacula,  36 
method  of  perineorrhaphy,  247 
metranoikter,  56 
operation  in  cystocele,  269 
History  taking,  25 
Hodge  pessary,  113 
Home,  operation  in,  394 
basins  for,  399 
care  of  instruments,  398 
choice  of  room,  394 
douche  bag  for,  398 
dressing  table  for,  397 
dressings  for,  398 
instrument  table  for,  397 
leg-supports  for,  396 
nurse's  kit  for,  401 
operating  table  for,  395 
preparation  of  patient,  394 
rubber  gloves  for,  399 
scrubbing  facilities  needed,  399 
sterile  water  for,  399 
supplies  required  for,  400 
Hormones,  384 
Horsehair  sutures,  preparation  of, 

404 
Hottentot  apron,  53 
Hunter,  gubernaculum  of,  183 
Hydatid  of  Morgagni,  155 
Hydatidiform  sarcoma  of  cervical 

canal,  149 
Hydrops  tubse,  163 
Hydrosalpinx,  163 
Hymen,  19 

abnormalities  of,  48 
Hyperemia    treatment    in    breast 

abscess,  351 
Hyperfunction,  glandular,  384 

of  ovary,  388 
Hypernephroma,  292 
Hyperplastic     glandular     endome- 
tritis, chronic,  127 
Hyperthyroidism  in  fibroid  tumors 

of  uterus,  134 
Hypertrophy  of  breast,  347 
of  cervix,  95 
of  clitoris,  53 
of  genital  organs,  53 
of  labia  majora,  53 


Hypertrophy  of  labia  minora,  53 
Hypofunction,  glandular,  384 

of  ovary,  387 
Hypophysis  cerebri,  386 
Hypospadias,  50 
Hysteralgia,  144 

Hysterectomy  in  menorrhagia,  333 
in  prolapse  of  uterus,  275 
in  salpingitis,  176 
supravaginal    abdominal,   in 

uterine  fibroids,  138 
vaginal,  in  cervical  cancer,  86 
technic,  88 
for  uterine  fibroids,  137 
Hysteropexy     in     retroversion     of 
uterus,  120 
technic,  121 
Hysterorrhaphy  in  retroversion  of 
uterus,  120 
technic,  121 

ICHTHYOL-GLYCERIN    tamponS,    42 

Imperforate  hymen,  48 
anus,  360 
rectum,  50,  360 
Implantation  of  ovary,  204 
Impregnation,  artificial,  56 
Incisional   hernia  after  abdominal 

operation,  224,  437 
Incisions  for  abdominal  section,  412 
Incontinence  of  urine,  277 

after  operation,  426 
Indigo-carmin  test  for  excretion  of 

urine  in  pyelitis,  290 
Indurating  cancer  of  cervix,  81 
Infantile  uterus,  144 
Infected  abdominal  wounds,  433 
causes,  433 

curative  treatment,  434 
from  catgut  ligatures,  433 
sinuses  in,  434 
symptoms,  433 
treatment,  433 
type  of  discharge  from,  433 
Inferior  vesical  fissure,  50 
Infiltration  anesthesia  in  abdominal 

section,  409 
Infundibulopehdc  ligament,  24 
Inguinal  hernia,  224 
Injuries  of  birth  canal,  228 
classification,  228 
repair,  228 
of  rectum,  368 
to  pelvis,  229 


INDEX 


453 


Instillations,  45 

cervical  and  intra-uterine,  45 
colic  from,  46 
solutions  for,  45 
Instruments    for    abdominal    sec- 
tion, 411 
for  office  use,  39 
for  plastic  operation,  412 
sterilization  of,  38,  411 
table  for,  in  home  operation,  397 
Intermenstrual  pain,  326 
Internal  generative  organs,  20 
hemorrhage  after  operation,  421 
regeneration  of  blood  after, 

422 
symptoms,  421 
treatment,  422 
shock  and,  differentiation,  419 
secretion,  glands  of,  384 
of  ovary,  185 
Interstitial  cancer  of  cervix,  81 
endometritis,  chronic,  127 
fibroid  tumors  of  uterus,  131 
mastitis,  353 
Intestinal  obstruction  after  opera- 
tion, 428 
postoperative  vomiting  in,  424 
Intraligamentary  fibroids  of  uterus, 

131 
Intramural  fibroids  of  uterus,  131 
Intra-uterine  instillations,  45 
colic  from,  46 
douche,  47 
Inverted  nipple,  346 
Inversion  of  uterus,  145 
acute,  145 
causes,  145 
chronic,  145 
complete,  145 
complications,  145 
differential  diagnosis,  145 
incomplete,  145 
Spinelli  operation  in,  146 
symptoms,  145 
treatment,  146 
operative,  146 
lodin    solution,    counter-irritation 

with,  44 
Irreducible  prolapse  of  uterus,  274 

operation  in,  274 
Irregular   bleeding   irrespective   of 

menstruation,  330 
Irrigations,  46 
bladder,  46 


Irrigations,  syringe  for,  46 

urethral,  46 

uterine,  47 
Ischiorectal  abscess,  368 

treatment,  369 
Isthmus  of  Fallopian  tubes,  22 

Jars,  glass,  39 

Kangaroo-tendon  sutures,  prepa- 
ration of,  407 

Kidney,  anatomy,  283 
diseases  of,  289 
dystopic,  259 
floating,     256,     292.     See     also 

Floating  kidney. 
stone  in,  292 
tuberculosis  of,  292 

Knee-chest  position,  30 

reposition  in,  in  retroversion, 
no 

Knife,  electric  cautery,  uses  of,  377 

Knots,  for  sutures,  varieties,  403 

Kraurosis  vulvae,  64 

Labia,  cysts  of,  61 

dermatitis  of,  acute,  59 
lacerations  of,  237 
majora,  17 

hypertrophy  of,  53 
minora,  18 

hypertrophy  of,  53 
tumors  of,  solid,  61 
Lacerations    of     anterior     vaginal 
wall,  235 
consequences,  236 
diagnosis,  236 
of  cervix,  229 
bilateral,  230 
causes,  229 
consequences,  231 
diagnosis,  231 
kinds,  229 
repair  of,  232 
stellate,  230 
symptoms,  231 
terminations,  230 
trachelorrhaphy  in,  232 
treatment,  232 
unilateral,  230 
of  vulva  and  labia,  237 
Lactation  atrophy  of  uterus,  151 

uterus  during,  103 
Lateral  flexion  of  uterus,  107 


454 


INDEX 


Left  lateral  position,  30 

Leg  supports  for  home  operation, 

396 
Leiomyoma  uteri,  131 
Leukorrhea,  336 
bacteriology  of,  337 
characteristics,  337 
color  of  discharge  in,  337 
consistence  of  discharge  in,  337 
definition,  336 
diagnosis,  338 
from  cervical  polj'ps,  97 
from  cervix,  336 

gonorrheal     type,     treatment, 

340 
treatment,  340 
from  Fallopian  tubes,  337 

treatment,  341 
from  uterus,  337 
treatment,  341 
from  vulva,  336 

treatment,  338 
in  fibroird  tumors  of  uterus,  135 
in  vaginitis,  75 
in  virgins,  341 
mild  vaginitis  with,  339 
prognosis,  342 

quantity  of  discharge  in,  337 
radium  in,  341 
treatment,  338 
with  senile  vaginitis,  339 
Levator  ani  muscle,  24 

tears  of,  237 
Ligament,  infundibulopelvic,  24 

utero-ovarian,  24 
Ligaments  of  ovary,  182 
of  uterus,  21,  102 

cardinal,  21 
uterosacral,  102 
uterovesical,  102 
Ligatures,  preparation  of,  402 
Light,    artificial,    for   examination, 

.38,  39 

Finsen,  383 
Linear  cauterization  in  prolapse  of 

rectum,  370 
Linen  thread  sutures,  preparation 

of,  402 
Liquor  foUiculi,  23,  184 
Lithotomy  position,  28 
Lobar  mastitis,  353 
Lobular  mastitis,  353 
Local  applications,  43 

in  pruritus  vulvae,  66 


Local  applications,  indications  for, 
44. 
solutions  for,  44 
blood-letting,  46 
treatment,  methods,  41 
Lubricants  for  examination,  29 
Lupus  of  vulva,  64 

treatment,  65 
Lutein  cells,  185 
Lymphatic  cysts  of  labia,  61 

of  vagina,  71 
Lymphatics  of  ovar}^,  182 
of  pelvic  floor,  24 
of  uterus,  21 

Macule,   Saenger's,  in  inflamma- 
tion of  Bartholin's  gland,  58 
Malformations    of     rectum,     con- 
genital, 360 
Mammary  gland.     See  Breast. 
Mammillitis,  343 
Marriage,  effect  of,  on  dj-smenor- 

rhea,  327 
Martin  operation  in  cystocele,  268 
Mastitis,  348 

carcinosa,  350 

cause,  348 

chronic,  353 

suppurative,  354 

circumscribed,  353 

diffuse,  353 

interstitial,  353 

lobar,  353 

lobular,  353 

symptoms,  349 

treatment,  349 
Mastodynia,  348 
Mayo's    modification   of    Gilliam's 

operation  for  retroversion.  123 
Medulla  of  ovary,  23 
Melena  spuria,  344 
Membrana  granulosa,  23,  184 
Membranous   dysmenorrhea,   327 
Menopause,  333 

bleeding  at,  334 

mechanism,  333 

surgical,  140,  334  _ 

after     salpingitis,     treatment, 
178 

sj-mptoms,  333 

treatment  during,  334 

uterus  after,  103 
Menorrhagia,  328 

amount  of  flow  in,  328 


INDEX 


455 


Menorrhagia,  atmokausis  for,  332 

causes,  328 

in  young  girls,  329 

severe,  treatment,  330 

treatment,  328 

zestokausis  in,  333 
Menstruation,  317 

abnormalities  of,  322 

absence  of,  322.     See  also  Amen- 
orrhea. 

amount  of  flow,  317 

blood  in,  character  of,  317 

congestion  before,  320 

drugs  to  produce,  324 

duration  of  flow,  317 

endometrium  during,  319 

excessive,  328.     See  also  Menor- 
rhagia. 

factors  influencing,  317 

Goodman-von  Ott  curve  in,  321 

involution  after,  321 

irregular  bleeding  irrespective  of, 
330 

mechanism  of,  321 

molimina  of,  322 

painful,     325.     See     also     Dys- 
menorrhea. 

precocious,  319 

scanty,  325 

suppression  of,  acute,  325 

uterus  during,  319 

vicarious,  335 
Mesenteric  emboli  after  operation, 

432 
Mesosalpinx,  155 
Mesothorium,  383 

in  cervical  cancer,  92 
Mesovarium,  23,  182 
Metranoikter,  B.  C.  Hirst's,  56 

in  sterility,  55 
Metritis,  147 

symptoms,  147 

treatment,  147,  331 
Metrorrhagia,  330 

after  operation  in  extra-uterine 
pregnancy,  162 

causes,  330 

diagnosis  of  source,  330 

radium  in,  382 
Micromazia,  343 
Milk-leg,  430 

dangers  of,  431 

prognosis,  431 

symptoms,  430 


Milk-leg,  treatment,  431 

varieties,  430 
Mittelschmerz,  326 
Mons  veneris,  17 
Morcellation     in    uterine    fibroids, 

142 
Morgagni,  cysts  of,  155,  180 

hydatid  of,  155 
Moskowitz'operation  in  prolapse  of 

rectum,  370 
Mucosa  of  cervix,  79 
Mucous  cervical  polyps,  96 
Mulberry  nipple,  347 
Miillerian  ducts,  49 
Muscle,  bulbocavernosus,  24 

deep  transversus  perinei,  24 

levator  ani,  24 
Mushroom  nipple,  347 
Mycotic  vaginitis,  74 

treatment,  77 
Myoma  of  cervix,  95 

of  heart,  134 

of  uterus,  131 

of  vagina,  72 
Myomectomy,     abdominal,    m 
uterine  fibroids,  141 

vaginal,  in  uterine  fibroids,  142 
Myometrium,  21,  102 
Myosarcoma  of  uterus,  149 
Myrtiform  caruncles,  19,  48 
Myxedema,  385 

Nabothian  cysts,  96 

puncture  of,  46 
Nerves  of  ovary,  182 

of  uterus,  21 
Neuralgia  of  breast,  348 
Nipple,  abnormalities  of,  343 

conical,  347 

fissured,  344 
symptoms,  344 
treatment,  344 

hollow,  347 

inverted,  346 

malignant  dermatitis  of,  347 

mulberry,  347 

mushroom,  347 

stunted,  346 

supernumerary,  343 
Nipple-shields,  345 

care  of,  346 
Nitrate  of  silver  tampons,  42 
Non-gonorrheal  vulvitis,  63 
Novocain-adrenalin  anesthesia,  409 


456 


Nulliparae,  prolapse  of  uterus  in, 

causes,  149 
Nurse  for  office,  39 

preparations   of,    for   abdominal 
section,_  393 
for  operation,  401 
Nurse's  lat  for  home  operation,  401 

Obesity    associated    with    genital 
atrophy,  387 

treatment,  225 
Office,  instruments  for,  39 

nurse  for,  39 

treatment,  25 
Omophobia,  137 
One-child  sterility,  54 
Oophoritis,  201 

acute,  201 

chronic,  202 
Oophoron,  183 

cysts  of,  186 
Operating  table  for  home  operation, 

395  . 
Operation,     abdominal.     See     Ab- 
dominal section. 
anesthesia  for,  408 
antiseptic  solutions  for,  408 
choice  of  time  for,  401 
closure  of  abdomen  after,  413 
complications    after,    treatment, 

419 
disinfection    of    abdominal    skin 

for,  407 
foreign  bodies  in  abdomen  after, 

418 
hand  disinfection  for,  407 
in  private  house,  394.     See  also 

Home  operation. 
instruments  for,  411 
plastic.     See  Plastic  operation. 
preparation  of  assistants  for,  401 

of  dressings  for,  402 

of  ligatures  for,  402 

of  nurses  for,  401 

of  sheets  for,  402 

of  sponges  for,  402 

of  surgeon  for,  401 

of  towels  for,  402 
retention  of  urine  after,  439 
salt   solution  in  abdomen  after, 

418 
time  in  bed  after,  417 
Ophthalmia    in    gonorrhea,    treat- 
ment, 315 


INDEX 


Organotherapy,  ovarian,  387 

uses,  388 
pituitary,  387 
Ovary,  23 
abnormalities  of,  185 
abscess  of,  201 
absence  of,  185 
accessory,  185 
anatomy,  182 
arteries  of,  182 
atrophy  of,  185 
carcinoma  of,  204 
cirrhosis  of,  185 

d3-smenorrhea  from,  186 
congestion  of,  186 
cortex  of,  23 
cystadenoma  of,  187 

diagnosis,  190 

serous,  188 

symptoms,  190 

treatment,  193 
cysts  of,  186.     See  also  Cysts  of 

ovary. 
degenerations  of,  186 
descent  of,  183 
development  of,  183 
diseases  of,  185 
displacements  of,  200 
endothelioma  of,  205 
examination  for,  29 
external  appearance,  23 
extracts  of,  388 

uses,  389 
fossa  of,  182 
hematoma  of,  tarry,  187 
hilus,  23,  182 
histologic  divisions,  182 
h3^erfunction  of,  388 
hj-pofunction  of,  388 
implantation  of,  204 
inflammation  of,  201.     See  also 

Oophoritis. 
internal  secretion  of,  185,  387 
ligaments  of,  182 
lymphatics  of,  182 
medulla  of,  23 
nerves  of,  182 

prolapse  of,  200.     See  also  Pro- 
lapse of  ovary. 
relations  of,  182 
sarcoma  of,  205 
stigma  of,  184 
teratoma  of,  189 

symptoms,  191 


INDEX 


457 


Ovary,  transplantation  of,  204 

tuberculosis  of,  206 

tumors  of,  solid,  204 
malignant,  204 
Overdistention  of  bladder,  302 
Ovigenous  cysts  of  ovary,  186 
Ovulation,  normal,  184 

Pagenstecher  thread  sutures, 

preparation  of,  402 
Paget's  disease,  347 
Pain,  coccygeal,  causes  of,  260 

in  cervical  cancer,  83 

in  vaginitis,  75 

intermenstrual,  326 

right-sided,  causes,  290 
Painful  coitus,  61 

menstruation,  325.     See  also  Z)y5- 
menorrhea. 
Palmas  plicatae,  79 
Pampiniform  plexus,  21 

varicocele  of,  181 
Pancreas,     internal     secretion    of, 

387. 
Panhysterectomy,     abdominal,    in 

cervical  cancer,  86 
Papilloma  of  rectum,  372 
Paracystium,  208 
Parametrial  hematoma,  213 
Parametritis,  208 
-  causes,  208 

chronic,  212 

diagnosis,  differential,  209 

operative  treatment,  209 

palliative  treatment,  209 

pathology,  208 

pelvic  peritonitis  and,   differen- 
tiation, 209 

pointing  of  abscess  in,  210 

posterior  vaginal  section  in,  210 

prognosis,  212 

symptoms,  209 

terminations,  209 

treatment,  209 
Parametrium,  102,  207 
Paraproctiurn,  208 
Parathyroid  glands,  386 
Paroophoron,  183 

cysts  of,  186 
Parovarium,  49,  183 

cysts  of,  186,  188 
symptoms,  190 
with  pedicle,  treatment,  193 
Patent  urachus,  226 


Patient,   examination  of,   26.     See 
also  Examination. 
preparation    of,    for    abdominal 
section,  392 
for  operation  at  home,  394 
for  vaginal  operation,  393 
Pedunculated  cervical  polyps,  97 
Pelvic  anatomy,  normal,  17 

cellulitis,    208.     See    also   Para- 
metritis. 
connective  tissue,  anatomy,  207 
floor,  24 
lymphatics  of,  24 
relaxation  of,  237 
tears  of,  237 
hematocele,  158,  213 

in      extra-uterine     pregnancy, 

infection,     abdominal     drainage 

after  operation  in,  216 
organs,  examination  of,  28.     See 

also  Examination,  pelvic. 
peritonitis,  214 

in  acute  salpingitis,  167 
parametritis   and,    differentia- 
tion, 209 
Pelvis,  injuries  to,  229 
Percy  low-heat  cautery  in  cervical 

cancer,  91 
Perforation  of  rectum  by  sutures  in 

plastic  operation,  440 
Perimetrium,  102 
Perineorrhaphy,  Emmet's  method, 

243 
Hegar's  method,  243 
B.  C.  Hirst's  method,  247 
Perineum,  dermatitis  of,  acute,  59 
tears  of,  237.     See  also  Tears  of 
perineum. 
Perisalpingitis,  179 
Peritoneal  coat  of  uterus,  102 
Peritoneum,  anatomy,  207 

diseases  of,  207 
Peritonitis,  214 

after  operation,  428 

diagnosis,  215 

diffuse,  214 

in  gonorrhea,  treatment,  315 

pelvic,  214 

in  acute  salpingitis,  167 
parametritis   and,    differentia- 
tion, 209 
postoperative  vomiting  in,  424 
treatment,  425 


458 


INDEX 


Peritonitis,    tubercular,    215.       See 
also  Tubercular  peritonitis. 
types,  214 
Pessary,  112 
action,  113 
care  of,  113 

contra-indications  to,  114 
Hodge,  113 
how  retained,  113 
in  anteflexion  of  uterus,  106 
in  cystocele,  265 
in  retroversion,  112 
after-treatment,  115 
dangers  from,  116 
indications  for,  113 
insertion  of,  114 
qualifications  of,  114 
Smith,  113 
stem,  in  sterility,  55 
Thomas,  113 
varieties,  113 
Phenolsulphonphthalein      test      in 

pyelitis,  290 
Phlebitis  after  operation,  429 
cause,  429 
symptoms,  430 
treatment,  430 
Phleboliths,  219 
Phlegmasia  alba  dolens,  430.     See 

also  Milk-leg. 
Piles,  363.     See  also  Hemorrhoids. 
Pineal  gland,  387 
Pituitary  gland,  386 

preparations  of,  uses,  387 
Placenta,  extracts  of,  390 
Plastic     operation,     complications 
after,  437 
fistula  after,  440 
hematoma  after,  439 
infection  after,  439 
instruments  for,  412 
perforation    of    rectum    by 

sutures  in,  440 
routine  after-care,  415 
vaginal  hemorrhage  after,  437 
treatment,  438 
Plexus,  pampiniform,  21 

varicocele  of,  181 
Plicae  palmatae,  21 
Pluriglandular  therapy,  391 
Pneumonia,  ether,  after  operation, 

426 
Pointed  condyloma,  60 
Polymazia,  343 


Polyp  of  cervix,  85,  96 
attachments,  97 
bleeding  in,  97 
degenerations  in,  97 
diagnosis,  97 
fibro-adenomatous,  96 
fibroid,  96 
leukorrhea  from,  97 
mucous,  96 
pedunculated,  97 
sessile,  97 
symptoms,  97 
treatment,  97 
of  rectum,  371 
of  uterus,  148 
Polythelia,  343 
Position,  dorsal,  28 
genupectoral,  30 
knee-chest,  30 
left  lateral,  30 
lithotomy,  28 
Sims',  30 
Postanesthetic  postoperative  vomit- 
ing, 423 
Postmammary  abscess,  353 
Postoperative  vomiting,  423 

in  intestinal  obstruction,  424 
in  peritonitis,  424 
treatment,  425 
postanesthetic,  423 
rectal  feeding  in,  425 
treatment,  424 
with  acidosis,  423 
treatment,  424 
Precocious  menstruation,  319 
Pregnancy,     abdominal,     primary, 
156 
secondary,  156 
cysts  of  ovar}'  and,  differentia- 
tion, 191 
effect  of  uterine  fibroids  on,  135 
extra-uterine,  156.     See  also  Ex- 
tra-uterine pregnancy. 
fibroid  tumors  of  uterus  in,  143 
in  horn  of    uterus  unicornis  or 

bicornis,  162 
uterus  during,  100 
Preparation  of  nurse  for  abdominal 
section,  393 
of  patient  for  abdominal  section, 

392 
for  operation  at  home,  394 
for  vaginal  operation,  393 
Prepuce  of  clitoris,  adherent,  60 


INDEX 


459 


Private  house,  abdominal  examina- 
tion in,  40 
examination  in,  39 
operation    in,    394.     See    also 
Home  operation. 
Procidentia  uteri,  271 
Proctitis,  368 
Proctodeum,  360 
Proctoscope,  359 
Prolapse  of  ovary,  200 
causes,  200 
symptoms,  200 
of  rectum,  369 

amputation  of  prolapsed  por- 
tion in,  370 
diagnosis,  369 
linear  cauterization  in,  370 
Moskowitz  operation  in,  370 
operative  treatment,  370 
palliative  treatment,  369 
of  urethra,  68 
of  uterus,  148,  271 
degrees,  271 
diagnosis,  272 
hysterectomy  in,  276 
in  nulliparse,  causes,  149 
irreducible,  274 

operation  in,  274 
mechanism,  271 
operative  treatment,  273 
palliative  treatment,  273 
symptoms,  272 
total,  271 
treatment,  273 
vaginitis  in,  75 
Prohf crating  cysts  of  ovary,  186 
Pruritus  in  vaginitis,  75 
ani,  370 
vulvas,  65 
causes,  65 

local  applications  in,  66 
surgical  treatment,  66 
symptoms,  65 
treatment,  65 
Pseudo-abscess      of        Bartholin's 

gland  57 
Pseudohermaphroditism,  54 
Pseudomucin  cysts  of  ovary,  187 
Pseudomyxoma  peritonei,  197,  199 
Pseudovaginismus,  73 
Pudendal  hernia,  67 
Puerperal  vaginitis,  75 
Pulmonary  embolism  after  opera- 
tion, 432 


Puncture  of  Nabothian  cysts,  46 
Purulent  salpingitis,  167 
Pus-tube,  165 
Pyelitis,  289 

antiseptic  injections  in,  288 

bacteria  in,  289 

diagnosis,  290 

examination  of  urine  in,  290 

functional  tests  in,  290 

palliative  treatment,  291 

predisposing  causes,  289 

prognosis,  291 

radical  treatment,  291 

site,  290 

surgical  treatment,  291 

symptoms,  289 

treatment,  291 

vaccine  treatment,  291 
Pyelography,  288 
Pyosalpinx,  165 

gonorrheal     and     streptococcic, 
differentiation,  171 

in  salpingitis,  167 

Radium,  379 

alpha  ray  of,  380 

beta  ray,  380 

C,  380 

dangers  and  disadvantages,  382 

effects  of,  382 

favorable  effects,  382 

gamma  ray  of,  380 

in  cervical  cancer,  91,  92,  382 

in  fibroids  of  uterus,  136 

in  leukorrhea,  341 

in  metrorrhagia,  382 

method  of  use,  381 

physical  properties,  379 

reaction  from,  382 
Rectal  examination,  29 

in  retroversion  of  uterus,  109 

feeding  for  postoperative  vomit- 
ing,_  42s 
Recti,  diastasis  of,  with  visceropto- 
sis, 220 
Rectocele,  262 

diagnosis,  263 

treatment,  263 
Rectovaginal  fistula,  diagnosis,  281 

treatment,  281 
Rectum,  359 

absent,  360 

adenoma  of,  371 

anomalies  of,  50 


460 


INDEX 


Rectum,  cancer  of,  372 

operative  treatment,  methods, 

373 
digital  examination,  359 
diseases  of,  359 
examination  of,  methods,  359 

technic,  360 
foreign  bodies  in,  363 
imperforate,  50,  360 
injuries  of,  368 
inflammation  of,  368 
inspection,  359 

malformations  of,  congenital,  360 
papilloma  of,  372 
perforation    of,    by    sutures    in 

plastic  operation,  440 
polyp  of,  371 

proctoscopic  examination,  359 
prolapse  of,  369 
sarcoma  of,  373 
specular  examination,  359 
stricture  of,  371 
tumors  of,  371 
benign,  371 
malignant,  372 
Recurrent  uterine  fibroids,  143 
Relaxation  of  sacro-iliac  joints,  229, 
262 
of  pelvic  floor,  238 
Renal  calculus,  292 
Repair  of  cervix,  232 
Reposition,  bimanual,  in  retrover- 
sion of  uterus,  no 
in  knee-chest  position  in  retro- 
version, no 
Repositor,  uterine,  38 
Retention  of  urine  after  operation, 

426,  439 
Retroflexion  of  uterus,  107 
Retroversion  of  uterus,  107 

adherent,  reposition  in,  112 
Alexander  operation  in,  116 
combined  with  section,  119 

technic,  120 
technic,  117 

with  Pfannenstiel  incision, 
n8 
technic,  119 
Baldy  operation  in,  122 

technic,  123 
causes,  107 

Coffey's  operation  in,  124 
degrees,  108 
diagnosis,  108 


Retroversion   of   uterus,   diagnosis, 
differential,  109 
Gilliam  operation  in,  123 

Mayo's  modification,  123 
hysteropexy  in,  120 

technic,  121 
hysterorrhaphy  in,  120 

technic,  121 
pathology,  109 
pessaries  in,  112 
after  treatment,  115 
dangers  from,  116 
predisposing  causes,  108 
rectal  examination  in,  109 
rectal  manipulation  in,  112 
reposition,  bimanual,  no 

in  knee-chest  posture,  no 
symptoms,  108 
time  of  occurrence,  108 
treatment,  no 
operative,  116 
palliative,  no 
uterine  sounds  in,  112 
vaginal  fixation  in,  125 
ventrofixation  in,  120 
ventrosuspension  in,  120 

technic,  121 
Webster  operation  in,  122 
technic,  123 
Right-sided  pain,  causes,  290 
Rontgen  ray.     See  X-ray. 
Round  ligaments  of  uterus,  102 
Rubber  gloves,  39 

for  home  operation,  399 
Rudimentary  vagina,  53 
Rupture  of  coccyx,  229 

Sacro-iliac  joints,  relaxation  of, 

229,  262 
Sacrosalpinx  serosa,  163 
Saenger's  macule  in  inflammation 

of  Bartholin's  gland,  58 
Salpingectomy  in  salpingitis,  1 73 
Salpingitis,  164 
acute  stage,  164 

operative  treatment,  173 
palliative  treatment,  171 
pelvic  peritonitis  in,  167 
symptoms,  168 
bimanual  examination  in,  170 
breaking  up  adhesions  in,  173 
chronic  stage,  165 

operative  treatment,  173 
palliative  treatment,  172 


INDEX 


461 


Salpingitis,    chronic    stage,   symp- 
toms, 168,  169 

closure  of  ends  of  tube  in,  167 

diagnosis,  170 

differential,  169,  170 

drainage  in,  177 

extra-uterine  pregnancy  and,  dif- 
ferentiation, 169 

hysterectomy  in,  176 

infections,  bacteria  in,  164 

isthmica  nodosa,  165 

operations  in,  173 
indications  for,  174 
ligature  material  for,  178 
conservatism  in,  176 

ovarian  cyst  and,  differeniation, 
169 

pathology,  164 

purulent,  167 

pyosalpinx  in,  167 

removal  of  both  tubes  in,  178 

routine   curettage  of   uterus  in, 
178 

salpingectomy  in,  1 73 

salpingo-oophorectomy  in,  174 

salpingo-oophorectomy  in,  dou- 
ble, sterility  after,  177 

salpingostomy  in,  176 

stages,  164 

surgical  menopause  after,  treat- 
ment, 178 

symptoms,  168 

treatment,  171 

vaginal  section  and  drainage  in, 
177 
Salpingo-oophorectomy  in  salpingi- 
tis, 174 
double,  sterility  after,  177 
Salpingostomy  in  salpingitis,  176 
Salt    solution    in    abdomen    after 

operation,  418 
Sarcoma,  hydatidiform,  of  cervical 
canal,  149 

of  breast,  358 

of  cervix,  85,  98 

of  ovary,  205 

of  rectum,  373 

of  uterus,  149 

age  of  occurrence,  149 
histology,  149 
metastasis  in,  150 
point  of  origin,  149 
prognosis,  150 
symptoms,  150 


Sarcoma  of  uterus,  treatment,  150 

of  vulva,  63 
Scanty  menstruation,  325 
Schatz    metranoikter    in    sterility, 

55 
Scirrhous  cancer  of  breast,  356 
Sclerosis  of  skin  of  vulva,  64 
Sebaceous  cysts  of  labia,  61 
Secretion,  internal,  glands  of,  384 
Segregation  of  urine,  288 
Senile  vaginitis,  75 

treatment,  77 

with    leukorrhea,     treatment, 

339 
Septate  hymen,  48 
Septic  vaginitis,  acute,  75 
Septum  formation  in  vagina,  72 
Serous  cystadenoma  of  ovary,  188 
Serum     treatment    in    gonorrhea, 

315 
Sessile  cervical  polyps,  97 
Sex  glands,  384 

Sheets,  preparation  of,  for  opera- 
tion, 402 
Shields,  nipple-,  345 

care  of,  346 
Shock  after  operation,  419 

internal  hemorrhage  and,  dif- 
ferentiation, 419 
symptoms,  419 
treatment,  420 
Sigmoidoscope,  359 
Silk  sutures,  preparation  of,  402 
Silkworm-gut  sutures,  preparation 

of,  404 
Silver  wire  sutures,  preparation  of, 
402 
nitrate  tampons,  42 
Sims'  position,  30 

speculum,  33 
Sinuses     in     infected     abdominal 

wounds,  434 
Sinusoidal  current,  properties,  375 
for    intra-uterine     treatment, 
376 
Skeleton  bivalve  speculum,  36 
Skene's  glands,  19 
abscess  of,  58 

chronic    infected,    instillations 
for,  45 
Skin,    abdominal,    disinfection   of, 

407 
Smith  pessary,  113 
Sound,  uterine,  38 


462 


INDEX 


Speculum,  bivalve,  33 

right  method  of  removal,  35 

of  using,  34 
skeleton,  36 

Sims',  T,s 
Sphincter  ani,  tears  through,  sj'mp- 

toms,  240 
Spinelli  operation  in   inversion  of 

uterus,  146 
Sponge  test,  56 
Sponges,  preparation  of,  402 
Squamous-cell    cancer    of    cervix, 

81 
Stem  pessary  in  sterility,  55 
Sterility,  54 

after   double   salpingo-oophorec- 
tom}^  in  salpingitis,  177 

artificial  impregnation  in,  56 

causes,  54 

from  dysmenorrhea,  327 

one-child,  54 

primarj',  54 

Schatz  metranoikter  in,  55 

secondary,  54 

stem  pessary  in,  55 

treatment,  55 

Wylie  drain  in,  55 
Sterilization  of  instruments,  38,  411 
Sterilizers,  39 
Stigma  of  ovary,  184 
Stitch,  wandering,  440 
Stitch-fisher,  use  of,  436 
Stoltz    purse-string    operation    in 

cystocele,  268 
Stomach,  dilatation  of,  acute,  after 

operation,  423 
Stone  in  bladder,  301 

in  kidney,  292 

in  ureter,  293 
Streptococcic    pyosalpinx,     gonor- 
rheal pyosalpinx  and,  differentia- 
tion, 171 
Stricture  of  rectum,  371 

of  urethra,  303 
Struma  ovarii,  189 
Stunted  nipple,  346 
Subinvolution  of  uterus,  150 
Submammary  abscess,  353, 
Submucous  fibroid  tumors  of  uterus, 

131 
Subserous  fibroids  of  uterus,  131 
Superinvolution  of  cervix,  80 

of  uterus,  151 
Superior  vesical  fissure,  50 


Supernumerary  breast,  343 
nipples,  343 

Suppression  of  menstruatioa  acute, 
325 

Suppurative  mastitis,  chronic,  354 

Suprarenal  glands,  386 

Supravaginal  abdominal  hj'sterec- 
tomy  in  uterine  fibroids,  138. 

Surgeon,  preparation  of,  for  opera- 
tion, 401 

Surgical  menopause,  334 

Suture   materials,    preparation   of, 
402 

Sutures,  knots  for,  varieties,  403 

Syphilis- of  breast,  354 
of  cervix,  85 

Table,  examination,  for  office,  ;i8 
Tampons,  41 

chronologic  arrangement  for  use, 

43  . 
insertion  of,  43 
medicated,  42 
method  of  making,  42 
uses,  42 
Tannic  acid  tampons,  42 
Tarry  hematoma  of  ovary,  187 
Tears  of  levator  ani,  237 
of  pelvic  floor,  237 
of  perineum,  237 

best  time  for  repair,  240 
causes,  238 
central,  240 

complete,  operation  for,  249- 
253 
after-treatment,  253 
factors  essential  to  success, 

254. 
operation  for,  technic,  250 
symptoms,  240 
delaj'ed  repair,  choice  of  opera- 
tion, 243 
Emmett  operation  for,  244 
Hegar's  method,  247 
B.  C.  Hirst's  method,  247 
preparations  for,  242 
technic,  241 
diagnosis,  238 

immediate  repair,  technic,  241 
incomplete,  repair  of,  time  in 

bed  for,  254 
preventive  treatment,  241 
repair  of,    routine    after-care, 
249 


INDEX 


463 


Tears  of  perineum,  results,  239 
symptoms,  238 
treatment,  241 
of  posterior  vaginal  wall,  237 
of  vagina,  237 
.  through    sphincter    ani,    symp- 
toms, 240 
Tenacula,  double,  36 
Tent,  sponge,  56 

tupelo,  56 
Teratoma  of  ovary,  189 

symptoms,  191 
Tetrelle,  345 
Theca  folliculi,  23,  184 
Thickened  hymen,  48 
Thomas'  pessary,  113 

uterine  applicator,  37 
Thymus  gland,  386 
Thyroid  gland,  384 
Tiedemann's  modification  for  stain- 
ing gonococcus,  308 
Towels,  preparation  of,  for  opera- 
tion, 402 
Trachelorrhaphy,      Emmet's,      in 

lacerations  of  cervix,  232 
Transplantation  of  ovary,  204 
Transversus  perinei  muscle,  deep, 

24 
Trigone  of  bladder,  283 
Trigonum,    urogenital,    muscle  of, 
,   tear  of,  235 
True  vaginismus,  73 
Tubal  abortion,  157 

in  extra-uterine  pregnancy,  157 
gestation,   156.     See  also  Extra- 
uterine pregnancy. 
Tubercular  ischiorectal  abscess,  369 
peritonitis,  215 
diagnosis,  215 
prognosis,  216 
symptoms,  215 
treatment,  216 
Tuberculosis  of  bladder,  299 
of  breast,  354 
of  cervix,  85,  98 
of  Fallopian  tubes,  179 
cause,  179 

contra-indications  to  opera- 
tion in,  180 
pathology,  179 
progress,  180 
symptoms,  179 
treatment,  180 
of  kidney,  292 


Tuberculosis  of  ovary,  206 
of  uterus,  152 
of  vagina,  72 
Tuberculous  endometritis,  128 
Tubes,  Fallopian,  22 
caliber,  23 
examination  for,  29 
fimbriated  extremity,  22 
isthmus,  22 
muscular  coat,  23 
uterine  portion,  22 
Tubo-ovarian  abscess,  167 
Tumors  of  abdominal  wall,  226 
of  breast,  354 
benign,  354 
malignant,  356 
of  Fallopian  tubes,  180 
benign,  180 
malignant,  180 
of  ovary,  solid,  204 
malignant,  204 
of  rectum,  371 
benign,  371 
malignant,  372 
solid,  of  labia,  61 
of  uterus,  fibroid,  131.     See  also 

Fibroid  tumors  of  uterus. 
of  vagina,  72 
Tupelo  tent,  56 


Ulceration  of  cervix,  98 
Umbilical  hernia,  222 
symptoms,  222 
treatment,  222 
operative,  223 
palliative,  222 
Urachus,  patent,  226 
Ureter,  anatomy,  283 
diseases  of,  293 
inflammation  of,  293 
stone  in,  293 
Ureteral  calculus,  293 

catheter,  uses  of,  288 
Ureterovaginal    fistula,    diagnosis, 
281 
treatment,  282 
Urethra,  anatomy,  283 
angioneuroma  of,  67 
atresia  of,  303 
blood-supply  of,  283 
caruncle  of,  67 
congenital  defects,  303 
defects  of,  50 


464 


INDEX 


Urethra,  diseases  of,  303 
irrigations  of,  46 
prolapse  of,  68 
stricture  of,  303 
Urethritis,  acute,  303 
chronic,  303 
gonorrheal,  311 
complications,  312 
prognosis,  311 
symptoms,  311 
treatment,  312 
Urethrocele,  264 
Urinary  tract,  anatomy,  283 
diseases  of,  283,  289 
lymphatics  of,  284 
nerves  of,  284 

technic  of  examination,  284 
veins  of,  284 
Urine,  examination  of,  in  pyelitis, 
290 
incontinence  of,  277 

after  operation,  426 
low   output  after  operation, 

437 

retention    of,    after    operation, 
426,  439 

segregation  of,  288 
Urogenital    trigonum,    muscle    of, 

tear  of,  235 
Uterine  applicator,  37 

colic  from  instillations,  46 

dressing  forceps,  37 

irrigations,  47 

repositor,  38 

sound,  38 
Utero-ovarian  ligament,  24 
Uterosacral  ligaments,  102 
Uterovesical  ligaments,  102 
Uterus,  20,  100 

abnormalities,  103 
of  position,  100 

adenomyomata  of,  143 

anteflexion    of,    103.     See    also 
Anteflexion  of  uterus. 

anteposition  of,  107 

anterior  displacement,  103 

anteversion  of,  107 

at  birth,  100 

atrophy  of,  lactation,  151 

bicornis,  pregnancy  in  one  horn, 
162 
unicollis,  49 

biforis,  50 

blood-vessels  of.  21 


Uterus,  broad  ligaments  of,  102 

cancer  of  fundus,  125.     See  also 
Cancer  of  uterus. 

cardinal  ligaments,  102 

congenital  anomalies,  49 

cordiformis,  49 

curettage  of,  routine,  in  salpin- 
gitis, 178 

didelphys,  49 

diseases  of,  100,  103 

displacement  of,  backward,  107 

double,  50 

duplex  bicornis,  49 

during  childhood,  100 
lactation,  103 
menstruation,  319 
pregnancy,  100 

excessive  pain   referred   to, 
144 

fibro myoma  of,  131 

flexion  of,  lateral,  107 

hemorrhage  from,  electricity  in, 
376 

incudiformis,  49 

infantile,  144 

inversion  of,  145.     See  also  In- 
version of  uterus. 

leiomyoma  of,  131 

leukorrhea  from,  337 
treatment,  341 

ligaments  of,  21,  102 
cardinal,  21 

lymphatics  of,  21 

means  of  support,  102 

muscle  of,  21 

myoma  of,  131 

myosarcoma  of,  149 

nerves  of,  21 

normal  position,  100 

perforation  of,  from  curettage  in 
endometritis,  130 

polyps  of,  148 

prolapse  of,  148,  271.     See  also 
Prolapse  of  iiterus. 

retroflexion  of,  107 

retroversion   of,    107.     See    also 
Retroversion  of  uterus. 

round  ligaments  of,  102 

sarcoma  of,   149.     See  also  Sar- 
coma of  uterus. 

septus,  49 

subinvolution  of,  150 
■  superinvolution  of,  151 

tuberculosis  of,  152 


INDEX 


465 


Uterus,     tumors  of,    fibroid,    131. 

See     also    Fibroid    tumors    of 

uterus. 
unicornis,  49 

pregnancy  in  one  horn,  162 
veins  ot,  21 
virgin,  loi 

Vaccines  in  gonorrhea,  treatment, 

315 
Vagina,  20 
absence  of,  53,  6g 
adenomyoma  of,  72 
cancer  of,  69.     See  also  Cancer 

of  vagina. 
chorionepithelioma  of,  69 
condyloma  of,  70 
cysts  of,  71 
diseases  of,  69 
fibro myoma  of,  72 
foreign  bodies  in,  71 
hemorrhage   from,  after    plastic 
operation,  437 
treatment,  438 
inflammation   of,    74.     See   also 

Vaginitis. 
leukorrhea  from,  treatment,  338 
myoma  of,  72 
operation     on,     preparation     of 

patient  for,  393 
rudimentary,  53 
septum  formation  in,  72 
tears  of,  237 
tuberculosis  of,  72 
tumors  of,  72 
varices  of,  77 
Vaginal  douche,  44 
directions  for,  44 
uses,  44 
fixation      in      retroversion       of 
uterus,  125 
.  hysterectomy  for  cervical  cancer, 
86  _ 
technic,  88 
for  uterine  fibroids,  137 
myomectomy  in  uterine  fibroids, 

142 
section  and  drainage  in  salpin- 
gitis, 177 
posterior,  in  parametritis,  210 
wall,  anterior,  lacerations  of,  235 
consequences,  236 
diagnosis,  236 
posterior,  tears  of,  237 
30 


Vaginismus,  72 
diagnosis,  73 
pseudo-,  73 
true,  73 
treatment,  73 

by  gradual  dilatation,  74 
in  obstinate  cases,  74 
Walthard's,  73 
Vaginitis,  74 
acute  septic,  75 
causes,  75 

chronic,  treatment,  76 
diagnosis,  75 
diffuse  granular,  74 
diphtheritic,  75 
emphysematous,  74 

treatment,  77  . 
from  gonorrhea,  75 

treatment,  76 
fungi  in,  75 

in  prolapse  of  uterus,  75 
leukorrhea  in,  75 
mild,  with  leukorrhea,  339 
mycotic,  74 

treatment,  77 
pain  in,  75 
prognosis,  77 
pruritus  in,  75 
puerperal,  75 
senile,  75 

treatment,  77 

with  leukorrhea,  treatment,  339 
symptoms,  75 
treatment,  76 
Varices  of  vagina,  77 
Varicocele  of  pampiniform  plexus, 
181 
of  vulva,  68 
Varicose  veins  of  vulva,  68 
Veins  of  ovary,  182 

of  uterus,  21 
Venereal  warts,  60 
fiat,  60 
pointed,  60 
Ventrofixation    in    retroversion    of 

uterus,  120 
Ventrosuspension    in    retroversion 
of  uterus,  120 
technic,  121 
Vesical  calculus,  301 
fissure,  inferior,  50 
superior,  50 
Vesicocervicovaginal  fistula,  282 
Vesico-urethral  fissure,  301 


466 


INDEX 


Vesicovaginal  fistula,  278 
colpocleisis  in,  281 
diagnosis,  278 
treatment,  279 
Vestibule  of  vulva,  18 
Vicarious  menstruation,  335 
Virgins,  uterus  in,  loi 

leukorrhea  in,  341 
Visceroptosis,     diastasis     of     recti 

with,  220 
Vomiting,  postoperative,  423.     See 

also  Postoperative  vomiting. 
Vulva,  17 

cancer  of,  62 

chancre  of,  60 

diseases  of,  57 

elephantiasis  of,  62 

epithelioma  of,  62 

inflammation  of,  63 

lacerations  of,  237 

leukorrhea  from,  336 
treatment,  338 

lupus  of,  64 
treatment,  65 

pruritus  of,  65 

sarcoma  of,  63 

sclerosis  of  skin  of,  64 

tubercular  ulceration  of,  64 
treatment,  65 

varicocele  of,  68 

varicose  veins  of,  68 

vestibule  of,  18 
Vulvitis,  63 

nongonorrheal,  63 
Vulvovaginal  abscess,  57 

glands,  19 
Vulvovaginitis,  312 


Walthard   treatment   of   vaginis- 
mus, 73 
Wandering  stitch,  440 
Warts,  venereal,  60 
flat,  60 
pointed,  60 
Watkins-Freund-Wertheim    opera- 
tion in  cystocele,  269 
Webster  operation  in  retroversion 
of  uterus,  122 
technic,  123 
Wertheim  abdominal  panhysterec- 
tomy in  cervical  cancer,  86 
Whites,  336.     See  also  Leukorrhea. 
Wound,  abdominal,  bursting  open 
of,  436 
infected,  433 
Wylie  drain  in  anteflexion  of  uterus, 
106 
in  sterility,  55 


X-RAY,  378 
burns,  378 
disadvantages    and    dangers    of, 

379  . 
in  cervical  cancer,  91 
in  fibroids  of  uterus,  136 
uses  of,  in  diagnosis,  379 

in  treatment,  379 


Youth,  amenorrhea  of,  323 


Zestokausis  in  menorrhagia,  T)T,2, 
Zona  pellucida,  184 


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Professor  of  Obstetrics  at  Northwestern  University  Medical 
School,  Chicago.  Large  octavo  of  1087  pages,  with  938  illus- 
trations,   175    in    colors.     Cloth,    ^8.00    net. 

Published  August,  1915 
SECOND  EDITION 

You  will  pronounce  this  new  book  the  most  elaborate,  the  most  superbly 
illustrated  work  on  Obstetrics  you  have  ever  seen.  Especially  will  you  value 
the  938  illustrations,  all,  with  but  few  exceptions,  original,  and  the  best  work 
of  leading  medical  artists.  Some  175  of  these  illustrations  are  in  color. 
Such  a  magnificent  collection  of  obstetric  pictures — and  with  really  pracHcai 
yaiue — has  never  before  appeared  in  one  book. 

You  will  find  the  text  extremely  practical  throughout  Diagnosis  is  fea- 
tured, and  the  relations  of  obstetric  conditions  and  accidents  to  general  medi- 
cine, surgery,  and  the  specialties  are  brought  into  prominence. 

Regarding  Treatment:  You  get  here  the  verj-  latest  advances  in  this  field, 
and  you  can  rest  assured  every  method  of  treatment,  every  step  in  operative 
technic,  is  just  right.  Dr.  DeLee' s  twenty-one  years'  experience  as  a  teacher 
and  obstetrician  guarantees  this. 

Worthy  of  your  particular  attention  are  the  descriptive  legends  under  the 
illustrations.  These  are  unusually  full,  and  by  studying  the  pictures  serially 
with  their  detailed  legends  you  are  better  able  to  follow  the  operations  than 
by  referring  to  the  pictures  from  a  distant  text — the  usual  method. 

Prof.  W.  Stoeckel,   Kiel,  Germany 

"  Dr.  DeLee's  Obstetrics  deserves  the  greatest  recognition.  The  whole  work  is  of 
such  sterling  character  through  and  through  that  it  must  be  ranked  with  the  best  works  of 
our  literature." 


Norris'  Gonorrhea  in  Women 

Gonorrhea  in  Women.  By  Charles  C.  Norris,  M.  D.,  Instructor 
in  Gynecology,  University  of  Pennsylvania.  With  an  Introduction  by 
John  G.  Clark,  M.  D.,  Professor  of  Gynecology,  University  of 
Pennsylvania.  Large  octavo  of  520  pages,  illustrated.  Cloth,  ^6.50 
ngt  PubUshed  May,  1513 


OBSTETRICS 


Davis'  Manual  of  Obstetrics 

Manual  of  Obstetrics.  By  Edward  P.  Davis,  M.  D., 
Professor  of  Obstetrics  in  Jefferson  Medical  College.  i2mo  of 
463  pages,  with  171  original  illustrations.     Cloth,  ^2.25  net. 

Published  September,  1914 
ORIGINAL   ILLUSTRATIONS 

Dr.  Davis'  manual  is  a  concise  text-book  of  exceptional  value.  Dr.  Davis, 
himself  a  teacher  of  many  years'  experience,  knows  the  requirements  of  such 
a  work  and  has  here  supplied  them.  You  get  anatomy  of  the  normal  and  ab- 
normal bony  pelvis,  physiology  of  impregnation,  anatomy  of  the  birth  canal 
in  pregnancy,  growth  and  development  of  the  embryo.  You  get  a  full  and  clear 
discussion  of  pregnancy — its  diagnosis,  physiology,  hygiene,  pathology.  You 
get  the  causes  and  treatment  of  labor,  the  physiology,  conduct,  pathology ; 
the  puerperal  period — care  of  the  mother  and  child  ;  obstetric  surgery,  fetal 
pathology,  mixed  feeding,  and  medicolegal  aspects  of  obstetric  practice. 


Davis'  Operative  Obstetrics 

operative  Obstetrics.  By  Edward  P.  Davis,  M.  D.,  Pro- 
fessor of  Obstetrics  at  Jefferson  Medical  College,  Philadelphia. 
Octavo  of  483  pages,  with  264  illustrations.     Cloth,  ^5.50  net. 

Published  September,  1911 
INCLUDING   SURGERY   OF   NEWBORN 

Dr.  Davis'  new  work  on  Operative  Obstetrics  is  a  most  practical  one,  and 
no  expense  has  been  spared  to  make  it  the  handsomest  work  on  the  subject 
as  well.  Every  step  in  every  operation  is  described  minutely,  and  the  technic 
shown  by  beautiful  new  illustrations.  The  section  given  over  to  surgery  of 
the  newborn  you  will  find  unusually  valuable.  It  gives  you  much  informa- 
tion you  want  to  know — facts  you  can  use  in  your  work  every  day.  There 
is  an  excellent  chapter  on  anesthesia  in  obstetrics. 

The  Lancet,  London 

"  The  best  and  most  interesting  part  of  the  book  is  the  summary  of  results  given  at  the 
end  oi  the  chapters  and  compiled  from  the  author's  own  experience  and  from  the  literature." 


SAUNDERS'  BOOKS   ON 


Ashton's 
Practice  of  Gynecology 

SIXTH  EDITION— published  October.  1916 

The  Practice  of  Gynecology.  By  W.  Easterly  Ashton, 
M.D.,  LL.D.,  Professor  of  Gynecology  at  the  Medico-Chirurgical 
College,  Graduate  School  of  Medicine,  University  of  Pennsyl- 
vania. Octavo  of  1097  pages,  containing  1052  original  line- 
drawings.     Cloth,  ^6.50  net. 

Among  the  important  new  matter  may  be  mentioned  the  De  Keating-Harl 
fiilguration  treatment,  Coley's  mixed  toxins  for  sarcoma  of  the  genito-urinarj 
organs,  the  cutireaction  of  von  Pirquet  in  the  diagnosis  of  tuberculosis,  "  606  " 
for  syphilis,  the  hormone  theory,  the  Fowler-Murphy  treatment  of  suppurative 
peritonitis,  tincture  of  iodin  in  sterilization,  and  Baldy's  new  round  ligament 
operation  for  retrodisplacement.  Notliing  is  left  to  be  taken  for  granted,  the 
author  not  only  telling  his  readers  in  eveiy  instance  what  should  be  done,  but 
also  precisely  how  to  do  if.  A  distinctly  original  feature  of  the  book  is  the 
illustrations,  numbering  1058  line  drawings  made  especially  under  the  author's 
personal  supervision. 

From  its  first  appearance  Dr.  Ashton"s  book  set  a  standard  in  practical 
medical  books  ;  that  he  lias  produced  a  work  of  unusual  value  to  the  medical 
practitioner  is  shown  by  the  demand  for  new  editions. 

Howard  A.  Kelly,  M.  D., 

Professor  of  Gynecologic  Surgery,  Johns  Hopkins  University 

"It  is  different  trom  anything  that  has  as  yet  appeared.  The  illustrations  are  particu- 
larly clear  and  satisfactory.  One  specially  good  feature  is  the  pains  with  which  you 
describe  so  many  details  so  often  left  to  the  imagination." 

Cluo'les  B.  Penrose.  M.  D., 

Formerly  Professor  of  Gyttecology,  University  of  Pennsylvania. 

"  I  know  of  no  book  that  goes  so  thoroughly  and  satisfactorily  into  all  the  details  of 
everything  connected  with  the  subject.     In  this  respect  your  book  differs  from  the  others." 

George  M.  Edebohls,  M.D. 

Professor  of  Diseases  of  Women,  Ne-ai  York  Post-  Graduate  Medical  School. 
"  I  have  looked  it  through  and  must  congratulate  you  upon  having  produced  a  text- 
book most  admirably  adapted  to  teach  gynecology  to  those  who  must  get  their  knowledge, 
even  to  the  minutest  and  most  elementary  details,  from  books." 


GYNECOLOGY. 


Bandler's 
Medical     Gynecology 


Medical  Gynecology.  By  S.  Wyllis  Bandler,  M.  D., 
Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Med- 
ical School  and  Hospital.  Octavo  of  790  pages,  with  150  original 
illustrations.      Cloth,  ;^5. 50  net.  PubUshed  February,  1914 

THIRD  EDITION— 60  PAGES  ON  INTERNAL  SECRETIONS 

This  new  work  by  Dr.  Bandler  is  just  the  book  that  the  physician  en- 
gaged in  general  practice  has  long  needed.  It  is  truly  the  practitiotier' s  gyne- 
cology— planned  for  him,  written  for  him,  and  illustrated  for  him.  There  are 
many  gynecologic  conditions  that  do  not  call  for  operative  treatment ;  yet, 
because  of  lack  of  that  special  knowledge  required  for  their  diagnosis  and 
treatment,  the  general  practitioner  has  been  unable  to  treat  them  intelligently. 
This  work  gives  just  the  information  the  practitioner  needs. 
American  Journal  of  Obstetrics 

"  He  has  shown  good  judgment  in  the  selection  of  his  data.  He  has  placed  most 
emphasis  on  diagnostic  and  therapeutic  aspects.  He  has  presented  his  facts  in  a  manner 
to  be  readily  grasped  by  the  general  practitioner." 


Bandler's  Vaginal  Celiotomy 

Vaginal  Celiotomy.    By  S.  Wyllis  Bandler,  M.  D.    Octavo 
of  450  pages,  with  148  illustrations.     Cloth,  I5.00  net. 

SUPERB   ILLUSTRATIONS 

The  vaginal  route,  because  of  its  simplicity,  ease  of  execution,  absence  of 
shock,  more  certain  results,  and  the  opportunity  for  conservative  measures, 
constitutes  a  field  which  should  appeal  to  all  surgeons,  gynecologists,  and 
obstetricians.  Posterior  vaginal  celiotomy  is  of  great  importance  in  the  re- 
moval of  small  tubal  and  ovarian  tumors  and  cysts,  and  is  an  important  step 
in  tlie  performance  of  vaginal  myomectomy,  hysterectomy,  and  hystero- 
myomectomy.  Anterior  vaginal  celiotomy  with  thorough  separation  of  t'ie 
bladder  is  the  only  certain  method  of  correcting  cystocele.  January,  1911 

The  Lancet,  London 

"  Dr.  Bandler  has  done  good  service  in  writing  this  book,  which  gives  a  very  clear 
description  of  all  the  operations  which  maj'  be  undertaken  through  the  vagina.  He  makes 
»ut  a  strong  case  for  these  operations." 


SAUNDERS'  BOOKS  ON 


Hirst's   Obtetrics 

New  (8th)  Edition 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst, 
M.  D.,  Professor  of  Obstetrics  in  the  University  of  Pennsylania. 
Handsome  octavo  of  863  pages,  with  715  illustrations.      Cloth, 

I5.OO  net.  PubUshed  January,  1918 


The  revision  of  the  work  for  this  edition  was  so  thorough  and  complete  that 
the  book  had  to  be  entirely  reset.  Nothing  has  been  omitted  that  could  make 
this  work  a  practical,  valuable  text-book  embracing  all  the  modern  advances 
in  the  field.  Among  the  new  subjects  included  are  the  use  of  Dakin's  solu- 
tion and  of  the  sunlight  and  open-air  treatment  of  puerperal  infections,  a  new 
chapter  on  various  anesthesias  in  obstetrics,  and  another  on  the  repair  of  in- 
juries of  the  genital  tract  due  to  childbirth.  The  illustrations  form  one  of  the 
features  of  the  book.     They  are  numerous  and  most  of  them  are  original. 

British  Medical  Journal 

"  The  illustrations  in  Dr.  Hirst's  volume  are  far  more  numerous  and  far  better  exe« 
cuted,  and  therefore  more  instructive,  than  those  commonly  found  in  the  works  of  writers 
on  obstetrics  in  our  own  country." 


Hirst's  Diseases  of  Women 

A  Text=Book  of  Diseases  of  Women.  By  Barton  Cooke 
Hirst,  M.  D.  Octavo  of  745  pages,  701  illustrations,  many  in 
colors.     Cloth,  ;^5.oo  net. 

SECOND  EDITION 

As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering 
diseases  of  women,  particular  attention  has  been  devoted  to  tliese  divisions. 
The  palliative  treatment,  as  well  as  the  radical  operation,  is  fully  described, 
enabling  the  general  practitioner  to  treat  many  of  his  own  patients  without 
referring  them  to  a  specialist.  Published  August,  1905 

Medical  Record,  New  York 

"Its  merits  can  be  appreciated  only  by  a  careful  perusal.  .  .  Nearly  one  hundred 
pages  are  devoted  to  technic,  this  chapter  being  in  some  respects  superior  to  the  descrip. 
tions  in  other  text-books." 


GYNECOLOGY. 


Kelly  and  Noble's  Gynecology 
and  Abdominal  Surgery 

Gynecology  and  Abdominal  Surgery.  Edited  by  Howard 
A..  Kelly,  M.  D.,  Professor  of  Gynecology  in  Johns  Hopkins 
University;  and  Charles  P.  Noble,  M.D.,  formerly  Clinical 
Professor  of  Gynecology  in  the  Woman's  Medical  College,  Phila- 
delphia. Two  imperial  octavo  volumes  of  850  pages  each,  con- 
taining 880  illustrations,  mostly  original.  Per  volume  :  Cloth, 
|8.oonet;  Halt  Morocco,  $9.50  net.  Volume  I  published  May, 
1907;  Volume-  II  published  June,  1908. 


WITH  880  ORIGINAL  ILLUSTRATIONS  BY  HERMANN  BECKER 
AND  MAX  BRODEL 

In  view  of  the  intimate  association  of  gynecology  with  abdominal  surgery 
the  editors  have  combined  these  two  important  subjects  in  one  work.  For 
this  reason  the  work  will  be  doubly  valuable,  for  not  only  the  gynecologist  and 
general  practitioner  will  find  it  an  exhaustive  treatise,  but  the  surgeon  also  will 
find  here  the  latest  technic  of  the  various  abdominal  operations.  It  possesses 
a  number  of  valuable  features  not  to  be  found  in  any  other  publication  cover- 
ing the  same  fields.  It  contains  a  chapter  upon  the  bacteriology  and  one  upon 
the  pathology  of  gynecology,  dealing  fully  with  the  scientific  basis  of  gyne- 
cology. In  no  other  work  can  this  information,  prepared  by  specialists,  be 
found  as  separate  chapters.  There  is  a  large  chapter  devoted  entirely  to 
medical  gynecology,  written  especially  for  the  physician  engaged  in  general 
practice.  Heretofore  the  general  practitioner  was  compelled  to  search  through 
an  entire  work  in  order  to  obtain  the  information  desired.  Abdominal  sur- 
gery proper,  as  distinct  from  gynecology,  is  fully  treated,  embracing  operations 
upon  the  stomach,  upon  the  intestines,  upon  the  liver  and  bile-ducts,  upon  the 
pancreas  and  spleen,  upon  the  kidney,  ureter,  bladder,  and  the  peritoneum. 
Special  attention  has  been  given  to  modertt  technic.  The  illustrations  are  the 
work  of  Mr.  Hernia?in  Becker  and  A'fr.  Alax  Br'odel. 

American  Journal  of  the  Medical  Sciences 

"  It  is  needless  to  say  that  the  work  has  been  thoroughly  done  :  the  names  of  the  authors 
and  editors  would  guarantee  this  ;  but  much  may  be  said  in  praise  of  the  method  of  presen- 
tation, and  attention  mav  be  called  to  the  inclusion  of  matter  not  to  be  found  elsewhere." 


SAUNDERS'    BOOKS    ON 


THE  BEST  ilLIIlCnCClIl  STANDARD 

Illustrated  Dictionary 

The  New  (9th)  Edition,   Reset 


The  American  Illustrated  Medical  Dictionary.  A  ne^v 
and  complete  dictionary  of  the  terms  used  in  Medicine,  Surgery, 
Dentistry,  Pharmacy,  Chemistry,  Veterinary  Science,  Nursing, 
and  all  kindred  branches;  with  over  loo  new  and  elaborate 
tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
DoRLAND,  M.D.,  Editor  of  '' The  American  Pocket  Medical 
Dictionary."  Large  octavo,  1179  pages,  bound  in  full  flexible 
leather.     Price,  ^5.00  net;  with  thumb  index,  $5.50  net. 

A  KEY  TO  MEDICAL  LITERATURE 

Gives  a  Maximum  Amount  of  Matter  in  a  Minimum  Space 

ENTIRELY  RESET— 2000  NEW  WORDS 

This  edition  is  not  a  makeshift  revision.  The  editor  and  a  corps  of  expert 
assistants  have  been  working  on  it  for  two  years.  Result — a  thoroughly  down- 
to-the-minute  dictionary,  unequalled  for  completeness  and  usefulness  by  any 
other  medical  lexicon  published.  It  meets  your  wants.  It  gives  you  all  the 
new  words,  and  in  dictionary  service  new  words  are  what  you  want.  Then,  it 
has  two-score  other  features  that  make  it  really  a  Medical  Encyclopedia. 

Published  September,  1917 


PERSONAL   OPINIONS 


Howard  A.  Kelly,  M.  D.. 

Professor  of  Gy7iecologic  Surgery,  fohns  Hopkins  University ,  Baltimore. 
"  Dr.  Borland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  conve- 
nient size.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren.  M.D..  LL.D.,  F.R.C.S.  (Hon.) 

Professor  of  Surgery,  Harvard  Medical  School. 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.     It  is  very  complete  and 
of  convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


DISEASES   OF   WOMEN. 


Webster's 
Diseases   qf  Women 


Diseases  of  Women.  By  J.  Clarence  Webster,  M.  D. 
(Edin.),  F.  R.  C.  p.  E.,  Professor  of  Gynecology  and  Obstetrics 
in  Rush  Medical  College.  Octavo  of  712  pages,  with  372  illus- 
trations.    Cloth,  ^7.00  net, 

FOR  THE  PRACTITIONER 

Dr.  Webster  has  written  this  work  especially  for  the  general  practitioner, 
discussing  the  clinical  features  of  the  subject  in  their  widest  relations  tc 
general  practice  rather  than  from  the  standpoint  of  speciaHsm.  The  magni- 
ficent illustrations,  three  hundred  and  seventy-two  in  number,  are  nearly  all 
original.  Drawn  by  expert  anatomic  artists  under  Dr.  Webster's  direct  super- 
vision, they  portray  the  anatomy  of  the  parts  and  the  steps  in  the  operations 
with  rare  clearness  and  exactness.  Published  January,  1907 

Howard  A.  Kelly,  '^.Yi,^  Professor  0/ Gynecologic  Surgery,  Johns  HopkinsUniversity. 

"  It  is  undoubtedly  one  of  the  best  works  which  has  been  put  on  the  market  within 
recent  years,  showing  from  start  to  finish  Dr.  Webster's  well-known  thoroughness.  The 
illustrations  are  also  of  the  highest  order." 


Webster's  Obstetrics 

A  Text=Book  of  Obstetrics.  By  J.  Clarence  Webster, 
M.  D.  (Edin.),  Professor  of  Obstetrics  and  Gynecology  in  Rush 
Medical  College.       Octavo  of   767   pages,   illustrated.      Cloth, 

^5.00  net.  Published  July,  1903 

Medical  Record,  New  York 

"  The  author's  remarks  on  asepsis  and  antisepsis  are  admirable,  the  chapter  on  eclamp- 
sia is  full  of  good  material,  and  ...  the  book  can  be  cordially  recommended  as  a  safe 
guide." 


SAUNDERS'    BOOKS    ON 


Kelly  and  Cullen's 
Myomata  of  the  Uterus 

Myomata  of  the  Uterus.  By  Howard  A.  Kelly,  M.  D., 
Professor  of  Gynecologic  Surgery  at  Johns  Hopkins  University; 
and  Thomas  S.  Cullen,  M.  B.,  Associate  in  Gynecology  at 
Johns  Hopkins  University.  Large  octavo  of  about  700  pages, 
with  388  original  illustrations  by  August  Horn  and  Hermann 
Becker.     Cloth,  ^7.50  net. 

A  MASTER  WORK 
ILLUSTRATED  BY  AUGUST  HORN   AND   HERMANN   BECKER 

This  monumental  work,  the  fruit  of  over  ten  years  of  untiring  labors,  will 
remain  for  many  years  the  last  word  upon  the  subject.  Written  by  those  men 
who  have  brought,  step  by  step,  the  operative  treatment  of  uterine  myoma  to 
such  perfection  that  the  mortality  is  now  less  than  one  per  cent.,  it  stands  out 
as  the  record  of  greatest  achievement  of  recent  times. 

The  illustrations  have  been  made  with  wonderful  accuracy  in  detail  by  Mr. 
August  Horn  and  Mr.  Hermann  Becker,  whose  superb  work  is  so  well  known 
that  comment  is  unnecessary.  For  painstakmg  accuracy,  for  attention  to  every 
detail,  and  as  an  example  of  the  practical  results  accruing  from  the  associa- 
tion of  the  operating  amphitheater  with  the  pathologic  laboratory,  this  work 
will  stand  as  an  enduring  testimonial.  Published  May,  1909 

Surgery,  Gynecology,  aaid  Obstetrics 

•'  It  must  be  considered  as  the  most  comprehensive  work  of  the  kind  yet  published.  It 
will  always  be  a  mine  of  wealth  to  future  students." 

New  York  Medical  Journal 

"  Within  the  covers  of  this  monograph  every  form,  size,  variety,  and  complication  of 
uterine  fibroids  is  discussed.  It  is  a  splendid  example  of  the  rapid  progress  of  American 
professional  thought." 

Bulletin  Medical  loid  Chirurgical  Faculty  of  Maryland 

"  Few  medical  works  in  recent  years  have  come  to  our  notice  so  complete  in  detail,  so 
well  illustrated,  so  practical,  and  so  far  reaching  in  their  teaching  to  general  practitioner 
specialist,  and  student  alike." 


GYNECOLOGY  AND    OBSTETRICS. 


Penrose's 
Diseases  of  Women 

Sixth  Revised  Edition 


A  Text=Book  of  Diseases  of  Women.  By  Charles  B. 
Penrose,  M.  D.,  Ph.  D.,  formerly  Professor  of  Gynecology  iij 
the  University  of  Pennsylvania ;  Surgeon  to  the  Gynecean  Hos- 
pital, Philadelphia.  Octavo  volume  of  550  pages,  with  225  fine 
original  illustrations.     Cloth  $3. 75  net.  Published  March,  i908 

ACCURATE 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called 
for,  and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students. 
Indeed,  this  book  has  taken  its  place  as  the  ideal  work  for  the  general  prac- 
titioner. The  author  presents  the  best  teaching  of  modern  gynecology,  un- 
trammeled  by  antiquated  ideas  and  methods.  In  every  case  the  most  modern 
and  progressive  technique  is  adopted,  and  the  main  points  are  made  clear  by 
excellent  illustrations. 

Howard  A.  Kelly,  M.D., 

Projessor  of  Gynecologic  Surgery,  Johns  Hopkins  University,  Baltimore. 
"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women '  received.     I 
have  already  recommended  it  to  my  class  as  the  best  book." 


Cullen's  Uterine  Adenomyoma 

Uterine  Adenomyoma.  By  Thomas  S.  Cullen,  M.  D.,  Asso- 
ciate Professor  of  Gynecology,  Johns  Hopkins  University.  Octavo 
of  275  pages,  with  original  illustrations  by  Hermann  Becker  and 
August  Horn.     Cloth,  $5.00  net.  Published  May,  1908 

Cullen's  Cancer  of  Uterus 

Cancer  of  the  Uterus.  By  Thomas  S.  Cullen,  M.  B.,  Asso- 
ciate Professor  of  Gynecology,  Johns  Hopkins  University.  Large 
octavo  of  693  pages,  with  over  300  colored  and  half-tone  text-cuts 
and  eleven  lithographs.     Cloth,  $7.50  net;  Half  Morocco,  $8.50  net. 

Published  1900 


SAUNDERS'  BOOKS   ON 


Davis'  Obstetric  and 
Gynecolog;ic  Nursing' 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P. 
Davis,  A.  M.,  M.  D.,  Professor  of  Obstetrics  in  the  Jefferson 
Medical  College  and  Philadelphia  Polyclinic;  Obstetrician  and 
Gynecologist,  Philadelphia  Hospital.  i2mo  of  498  pages,  illus- 
trated.    Buckram  $2.00  net.  PubUshed  May,  1917 

NEW  (5th)   EDITION 

This  volume  gives  a  vety  clear  and  accurate  idea  of  the  maimer  to  meet 
the  conditions  arising  during  obstetric  and  gj-necologic  nursing.  The  fifth 
edition  has  been  thoroughly  revised. 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by 
a  perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can 
recommend." — The  Lancet,  London. 


American  Pocket  Dictionary      New  (loth)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A. 
Newman  Dorx,and,  A.  M.,  M.  D.  With  693  pages.  Full  leather, 
limp,  $1.25  net;  patent  thumb  index,  $1.50  net.  September,  1917 

James  W.  Holland,  M.  D., 

Professor  of  Chemistry  and  Toxicology  at  the  Jefferson  Medical  College,  Philadelphia. 

"I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior. 
I  can  recommend  it  to  our  students  without  reserve." 

Ashton*s  Obstetrics  Eighth  Edition 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.  D.,  Pro- 
fessor of  Gynecolog\s  University  of  Pennsylvania.  Cro\\Ti  octavo, 
290  pages,  125  illustrations.  Cloth,  $1.25  net.  In  Saunders'  Qnestion- 
Compend  Series.  PubUshed  January,  1917 

Galbraith's  Four  Epochs  of  Woman's  Life  Edition 

The  Four  Epochs  of  Woman's  Liee:  A  Study  in  Hygiene. 
Maidenhood,  Marriage,  Maternity,  Menopause.  By  Anna  M.  Gal- 
BRAiTH,  M.D.  With  an  Introductory  Note  by  John  H.  Musser,  M.D  . 
PubUshed  March,  1917.  i2mo  of  296  pages.     Cloth,  $1.50  net. 


GYNECOLOGY  AND    OBSTETRICS  13 


Bandler's  The  Expectant  Mother 

The  Expectant  Mother.  By  Samuel  Wyllis  Bandler,  M.  D., 
Professor  of  Diseases  of  Women,  New  York  Post-Graduate  Medical 
School  and  Hospital.  i2mo  of  213  pages,  illustrated.  Cloth,  $1.25 
net.  Published  August,  1916 

Montgomery's  Care  of  Gynecologic  Cases 

Care  of  Patients:  Before,  During,  and  After  Operation.  By  E. 
E.  Montgomery,  M.  D.,  LL.D.,  Professor  of  Gynecology  in  Jefferson 
Medical  College.     i2mo  of  149  pages,  illustrated.     Cloth,  $1.25  net. 

Published  December,  1916 

Macfarlane's  Gynecology  for  Nurses        Idwon 

A  Reference  Hand-Book  of  Gynecology  for  Nurses.  By  Cath- 
arine MacfarlANE,  M.  D.,  Gynecologist  to  the  Woman's  Hospital  of 
Philadelphia,  l6mo  of  1 56  pages,  with  70  illustrations.  Flexible  leather, 
^1.25  net.  Published  May,  1913 

A,   M.   Seabrook,   M.   D.,    IVoman's  Medical  College  of  Philadelphia. 

"  It  is  a  most  admirable  little  book,  covering  in  a  concise  but  attractive  way  the  sub- 
ject from  the  nurse's  standpoint." 

Cragin's  Gynecology  Eighth  EdWon 

Essentials  of  Gynecology.  By  Edwin  B.  Ceagin,  M.  D.,  Pro- 
fessor of  Obstetrics,  College  of  Physicians  and  Surgeons,  New  York. 
Crown  octavo,  240  pages,  62  illustrations.  Cloth,  $1.25  net.  In 
Saunders^  Question-Compend  Series.  Published  October,  1913 

Schaffer  and  Norris*  Gynecology  ^Ttfil 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of 
Heidelberg.  Edited,  with  additions,  by  Richard  C.  Norris,  A.  M., 
M.  D.,  Assistant  Professor  of  Obstetrics,  University  of  Pennsylvania. 
155  illustrations,  272  pages.     Cloth,  $3.50  net.  Published  1900 

Schaffer  and  Edgar's  Obstetrics 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treatment.  By 
Dr.  O.  Schaffer,  of  Heidelberg.  From  the  Second  Revised  German 
Edition.  Edited,  with  additions,  by  J.  Clifton  Edgar,  M.  D.,  Pro- 
fessor of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medi- 
cal School,  N.  Y.  With  122  colored  figures  on  56  plates,  38  text-cuts, 
and  315  pages  of  text.  Cloth,  $3.00  net.  In  Saunders'  Hand-Atlas 
Series.  Published  January,  19u: 


14  SAUNDERS'    BOOKS    ON 

Schaffer  and  Webster's 
Operative  Gynecology 

Atlas  and  Epitome  of  Operative  Gynecology.     By  Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J. 
Clarence  Webster,  M.  D.  (Edin.),  F.  R.  C.  P.  E.,  Professor  of 
Obstetrics  and  Gynecology  in  Rush  Medical  College,  in  affili- 
ation with  the  University  of  Chicago.  42  colored  lithographic 
plates,  many  text-cuts,  a  number  in  colors,  and  138  pages  of  text. 
In  Saunders'  Hand- Atlas  Series.     Cloth,  ^3.00  net. 

Much  patient  endeavor  has  been  expended  by  the  author,  the  artist,  and 
the  lithographer  in  the  preparation  of  the  plates  for  this  Atlas.  They  are  based 
on  hundreds  of  photographs  taken  from  nature,  and  illustrate  most  faithfully 
the  various  surgical  situations.  Dr.  Schaffer  has  made  a  specialty  of  demon- 
strating by  illustrations.  Published  1904 

Medical  Record,  New  York 

"The  volume  should  prove  most  helpful  to  students  and  others  in  gasping  details 
usually  to  be  acquired  only  in  the  amphitheater  itself." 


De  Lee's  Obstetrics  for  Nurses 

Obstetrics  for  Nurses.  By  Joseph  B.  DeLee,  M.  D., 
Professor  of  Obstetrics  in  the  Northwestern  University  Medical 
School,  Chicago ;  Lecturer  in  the  Nurses'  Training  Schools  of 
Mercy,  Wesley,  Provident,  Cook  County,  and  Chicago  Lying-in 
Hospitals.     i2mo  of  550  pages,  fully  illustrated. 

Published  July,  1917  Cloth,  $2.75  net. 

FIFTH  EDITION 

While  Dr.  DeLee  has  written  his  work  especially  for  nurses,  the  practi- 
tioner will  also  find  it  useful  and  instructive,  since  the  duties  of  a  nurse  often 
devolve  upon  him  in  the  early  years  of  his  practice.  The  illustrations  are 
nearly  all  original  and  represent  photographs  taken  from  actual  scenes.  The 
text  is  the  result  of  the  author's  many  years'  experience  in  lecturing  to  the 
nurses  of  five  different  training  schools. 

J.  Clifton  Edgar,  M.  D„ 

Professor  of  Obstetrics  and  Clinical  Midwifery ,  Cornell  University,  New  York. 
"  It  is  far  and  away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure 
in  recommending  it  to  my  nurses,  and  students  as  well." 


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